Every finding on record at Greene Health & Rehab Center

Based on review of facility policies, clinical records, observations, shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of five residents reviewed (Residents 1 and 4).Findings include: The facility policy for bathing and showering, dated March 2026, indicated that residents are bathed or showered to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Document if the resident refused the shower/tub bath, the reason why and the intervention taken. Notify the charge nurse if the resident refuses the shower/tub bath. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated May 13, 2026, revealed that the resident was cognitively intact, was dependent on staff for showers/bathing, and had diagnoses including open wound to right hip and paraplegia. A grievance form for Resident 1 dated June 23, 2026, revealed that he is not offered routine showers. Social worker met with the resident and determined he would prefer showers on Wednesday's daylight shift. Review of the activities of daily living (ADL) documentation for Resident 1 from July 2026, through August 26, 2026, revealed that he was to receive a shower on Wednesday's daylight shift. Showers were documented as not given on July 1, 8; August 5, 12 and 19 in the ADLS documentation and in the tasks and there was no documented evidence that the resident refused his showers. Interview with the Director of Nursing on August 27, 2026, at 4:04 p.m. confirmed that there was no documented evidence that Resident 1 received and/or refused his showers on the above-mentioned dates. A quarterly MDS assessment for Resident 4, dated August 6, 2026, revealed that the resident was cognitively impaired, was dependent on staff for showers/bathing, and had diagnoses including dementia.Review of the activities of daily living (ADL) documentation for Resident 4 from June 2026, through July 2026, revealed that he was to receive a shower on Wednesday's evening shift and Sunday's evening shift. Showers were documented as not given June 3, 7, 10, 14, 17, 21, 24, 28; July 4, 8, 15, 19, 26 and 29 in the ADLS documentation and in the tasks and there was no documented evidence that the resident refused his showers.Interview with the Facility Consultant on August 27, 2026, at 4:52 p.m. confirmed that there was no documented evidence that Resident 4 received and/or refused his showers on the above-mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to start a medication as recommended by a rheumatology consultation for one of 5 residents reviewed (Resident 3).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 10, 2026, revealed that the resident was cognitively intact, required staff assistance with daily care needs, and had diagnoses that included multiple sclerosis. A rheumatology consult, dated June 29, 2026, recommended administering 10 grams of Gammaked (a therapy that delivers concentrated antibodies from donated human plasma to help strengthen the immune system) subcutaneously every week. There was no documented evidence that Resident 3 was administered Gammaked after June 29, 2026. Interview with Director of Nursing on August 26, 2026, at 4:09 p.m. confirmed that there was no evidence that Resident 3 received weekly injections of Gammaked as recommended on June 29, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for one of five residents reviewed (Resident 2).Findings Include: The facility policy for psychoactive medication indicated that residents (or their resident representative) prescribed psychoactive medication will be educated on the risks/benefits of the medication and give informed consent before the medication is administered. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 29, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnoses that included depression and bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, activity levels, and the ability to concentrate). Progress note for Resident 2 dated March 19, 2026, indicated that the resident reported to the nurse practitioner that she did not want to take any sleeping pills and did not want to be on any antidepressant medication. Physician's orders for Resident 2, dated April 20, 2026, included for the resident to receive 50 milligrams (mg) of Trazadone (an antidepressant/psychotropic medication) daily. Review of the Medication Administration Record for Resident 2 dated April 2026 revealed that the resident received 50 mg of Trazadone on April 21, 22, and 23, 2026. There was no documented evidence in the resident's clinical record to indicate that the resident or the resident's representative was informed in advance of the risks and benefits of the medication and/or obtained consent to administer the medication. Interview with the Director of Nursing on August 26, 2026, at 2:05 p.m. revealed that she was unsure why Trazadone was administered to Resident 2 for three days and there was no documented evidence that the resident or the resident's representative was informed in advance of the risks and benefits of the medication and/or obtained consent to administer the medication prior to administering it on April 20, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a): Resident rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain diagnostic studies as recommended by a rheumatology consultation for one of 5 residents reviewed (Resident 3).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 10, 2026, revealed that the resident was cognitively intact, required staff assistance with daily care needs, and had diagnoses that included multiple sclerosis. A rheumatology consult, dated June 29, 2026, recommended a DXA bone density scan (test that measures the strength and mineral content of bones) be obtained. There was no documented evidence that Resident 3 had a DXA bone density scan after June 29, 2026. Interview with Director of Nursing on August 26, 2026, at 4:09 p.m. confirmed that there was no evidence that Resident 3 had a DXA bone density scan obtained as recommended on June 29, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of seven residents reviewed (Resident 1, 3).Findings include:A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 26, 2026, indicated that the resident was cognitively impaired and dependent on staff for daily care needs.A nursing note for Resident 1, dated June 29, 2026, at 11:18 a.m. indicated that the resident representative was notified of room change pending confirmation of type of insect found in room.Resident 1's clinical record, including the nursing notes, for June and July 2026 revealed no documented evidence that the type of insect found in her room was confirmed or that the facility's policy for bed bugs was followed.A quarterly MDS assessment for Resident 3, dated May 21, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care needs and had diagnoses that included dementia.A nursing note for Resident 3, dated June 29, 2026, at 11:18 a.m. indicated that the resident's representative was notified of room move pending confirmation of type of insect found in room.Resident 3's clinical record, including the nursing notes, for June and July 2026 revealed no documented evidence that the type of insect found in her room was confirmed or that the facility's policy for bed bugs was followed.Interview with the Director of Nursing on July 15, 2026, at 1:02 p.m. confirmed that there was no documented evidence in the clinical records of Residents 1 and 3 that the type of insect found in their room was confirmed or that facility's policy for bed bugs was followed and should have been.28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure timely completion of prescribed laboratory services for one of two residents reviewed (Resident 1).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 15, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for her daily care needs and had diagnoses that included heart failure. Physician's orders for Resident 1 dated May 19, 2026, included an order for urinalysis (involves checking the appearance, concentration and content of urine) and urine culture and sensitivity (a laboratory test used to diagnose urinary tract infections and find the most effective medication to treat them). Physician's orders dated May 27, 2026, included an order for urinalysis and urine culture and sensitivity.Nurse's note for Resident 1 dated May 19, 2026, at 1:03 p.m. revealed that a new order was received for a urinalysis and culture and sensitivity per the family's request. Review of the Medication Administration Record for Resident 1 dated May 2026 indicated that a urine specimen for urinalysis, culture and sensitivity was obtained on May 19, however there was no documented evidence that it was sent to the laboratory or that results were obtained. Nurse's note for Resident 1 dated May 29, 2026, at 10:55 a.m. revealed that the resident was discharged home accompanied by her daughter. A Nurse's note dated May 29, 2026, at 1:13 p.m. revealed that the resident's daughter was notified that the physician was calling a prescription into the pharmacy for an antibiotic for a urinary tract infection. Interview with Director of Nursing on June 11, 2026, at 3:08 p.m. confirmed that there was no evidence that urine for urinalysis and culture and sensitivity was sent to the lab or that results were obtained when it was ordered on May 19, 2026, and that the urinalysis and culture and sensitivity were not completed until May 27, 2026. The resident was discharged home prior to the results returning and treatment for the urinary tract infection started. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal representative (power of attorney) was given the opportunity to make decisions regarding physical/sexual contact between residents for one of 14 residents reviewed (Resident 12).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2026, indicated that the resident was severely confused, was independent with ambulation, and had diagnoses that included Korsakoff's dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors). Resident 12's clinical record revealed that his daughter, Family Member 1 was his power of attorney and decision maker.Observations of Resident 12 on April 21, 2026 at 10:22 a.m. revealed that he was walking with Resident 11 with her holding his arm as they walked. Staff redirected them from the exit door and had them sit together at the dining table.Nursing note for Resident 12, dated December 14, 2025 at 5:29 a.m. revealed that Resident 12 was observed talking with Resident 11, holding her hand and kissing her.Nursing note for Resident 12, dated December 14, 2025 at 1:24 p.m. indicated that Resident 12 was wandering the unit with Resident 11 and they were trying to leave the unit.Nurse's note for Resident 12, dated December 29, 2025 indicated that Resident 12 was walking with and holding hands with Resident 11.Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated.Interview with Family Member 1 on April 22, 2026 at 9:26 a.m. revealed that she was told in early December, shortly after Resident 12's admission, that Resident 11 had attached herself to him like he was her boyfriend. She stated that because her father is only [AGE] years old and is still married to her mother, she did not want him around Resident 11. She said that she had visited several times and each time Resident 11 would follow them around and tell Resident 12 that they needed to leave together. She said on March 12, 2026 the nurse phoned her and told her that her father was found in bed with Resident 11 and that he was exposed. She said she was angry and came to the facility within an hour or so and when she arrived he was sitting with Resident 11 on the bench in front of the nurse's station. She said he was holding Resident 11's hand and she had her head resting on his shoulder. She said she was angry because she asked that they be separated and that any contact between them not be permitted or encouraged. She said that she has made it very clear that she does not want her father to be around Resident 11.Interview with Assistant Director of Nursing on April 22, 2026 at 2:30 p.m. revealed that Resident 11 believes Resident 12 to be her boyfriend and that they are always together. She further stated that Resident 12's daughter has said she does not want her father with Resident 11, but that Resident 11 is too difficult to redirect.28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of facility policy, facility's assessment, clinical record reviews, observations, family interviews and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for four of six residents reviewed who reside in the Memory Impaired Unit (MIU) (Residents 9, 10, 11, 12) who had dementia which has led to frequent falls and behaviors.Findings include: The facility's assessment, dated April 6, 2026 revealed that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that the Life Enrichment staffing requirements were one full time director and three full time aides. A quarterly MDS assessment for Resident 9, dated March 30, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences. A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had diagnoses that included dementia. The resident's care plan, dated March 5, 2026, was not individualized to identify the resident's activity preferences. A quarterly MDS for Resident 11, dated March 29, 2026, revealed that the resident was cognitively impaired, ambulated independently, had verbal behaviors, and had diagnoses that included dementia. The resident's care plan, dated November 11, 2025, indicated that the resident had behaviors and that staff were to provide activities that resembled her prior lifestyle, however, the resident's care plan was not individualized to reflect the resident's prior lifestyle or what she enjoyed to do. A quarterly MDS assessment for Resident 12, dated March 18, 2026, revealed that the resident was cognitively impaired, ambulated independently, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences. Observations in the MIU on April 21, 2026 at 11:20 a.m. revealed that there were 14 residents sitting around the tables in the common room. The activity aide was playing music, but was not engaging the residents in any activity. One resident pulled her shirt over her head exposing her breasts multiple times and there were not always staff in the common room to pull her shirt down or cover her up. There were no further activities observed in the MIU on April 21, 2026. Observations in the MIU on April 22, 2026 at 10:00 a.m. revealed that the activity aide brought a coffee cart with donuts into the unit. At 10:20 a.m. the first resident was served a half a donut and a cup of iced tea. At 10:31 a.m. she finished passing donuts and drinks to the residents. There were two residents in the common room that were not offered donuts or drinks. She did not engage any residents in a group activity. Residents were observed wandering aimlessly, getting into the cupboards and drawers around the room, and yelling out. There were no other activities observed in the MIU on April 22, 2026. Observations in the MIU on April 22, 2026 at 10:46 a.m. revealed that there were two residents wandering the unit aimlessly, 11 residents sitting in the common area with no stimulation, and six residents sleeping in the common area. Nursing note for Resident 9, dated April 17, 2026 at 4:26 p.m. revealed that he was in a physical altercation with his roommate where he punched his roommate in the face. Nursing note for Resident 10, dated January 30, 2026 revealed that she fell out of bed onto the floor. Nursing note dated February 5, 2026 revealed that she fell while self-transferring. Nursing note dated February 6, 2026 revealed that Resident 10 was found in another resident's room, attempted to self-transfer and fell. Nursing note dated February 8, 2026 revealed that she fell while trying to self-transfer. Nursing note dated February 10, 2026 revealed that she threw herself on the floor after being redirected out of another resident's room. Nursing note dated March 16, 2026 revealed that she fell when trying to self-transfer in the common room. Nursing note dated March 18, 2026 revealed that she fell while attempting to self-transfer from one chair to another and that she had another fall in her later that night. Nursing note dated April 2, 2026 revealed that she attempted to self-transfer and fell to the floor in the common room. Nursing note dated April 4, 2026 revealed that the resident fell while trying to take herself to the bathroom. Nursing note dated April 8, 2026 revealed that the resident removed her ostomy bag (a bag connected to a surgical opening on the abdominal wall to allow feces to leave the body) and staff could not locate it and that the resident was smearing feces around in miscellaneous places. Nursing note dated April 15, 2026 revealed that the resident fell in her room while trying to self-transfer to her bed and later that evening had another fall in front of the nurse's station when trying to stand independently. Nursing note dated April 16, 2026 revealed that the resident fell while trying to take herself to the restroom. Nursing note dated April 17, 2026 revealed that the resident fell in her room while trying to self-transfer. Nursing note for Resident 11, dated December 16, 2025 revealed that the resident was spending more time with Resident 12 and that they were holding hands. Nursing note dated December 19, 2025 revealed that Residents 11 and 12 were trying to leave the unit and were unable to be separated from each other. Nursing note dated December 29, 2025 revealed that Resident 11 was walking with Resident 12 and holding hands and that staff were unable to redirect them. Nursing note dated January 7, 2026 revealed that Resident 11 continuously attempted to enter Resident 12's room. Nursing note dated March 6, 2026 revealed that Resident 11 punched another resident in the jaw and was then pushed to the floor by that resident. Nursing note dated March 12, 2026 revealed that Resident 11 was sitting on her bed with Resident 12 who had his pants unbuttoned and was exposed. Nursing note dated March 25, 2026 revealed that Resident 11 was attempting to hold Resident 12's hand and attempted to take him into her room. Nursing note for Resident 12, dated December 14, 2025 at 5:29 a.m. revealed that Resident 12 was observed talking with Resident 11, holding her hand and kissing her. Interview with Family Member 1 on April 22, 2026 at 9:26 a.m. revealed that she was told in early December, shortly after Resident 12's admission, that Resident 11 had attached herself to him like he was her boyfriend. She stated that because her father is only [AGE] years old and is still married to her mother, she did not want him around Resident 11. She said that she had visited several times and each time Resident 11 would follow them around and tell Resident 12 that they needed to leave together. She said on March 12, 2026 the nurse phoned her and told her that her father was found in bed with Resident 11 and that he was exposed. She said she was angry and came to the facility within an hour or so and when she arrived he was sitting with Resident 11 on the bench in front of the nurse's station. She said he was holding Resident 11's hand and she had her head resting on his shoulder. She said she was angry because she asked that they be separated and that any contact between them not be permitted or encouraged. She said that she has made it very clear that she does not want her father to be around Resident 11. Interview with Register Nurse 1 on April 21, 2026 at 12:53 p.m. revealed that there have not been any activities in the MIU for some time and that each resident has their own behaviors and sometimes they aren't able to get along with one another. Interview with Nurse Aide 2 on April 21, 2026 at 11:18 a.m. revealed that she is an agency aide but that she has come to the facility several times. She stated that she does not have time to do anything other than resident care and cannot watch the residents while she is in a room doing care. She said that the residents wander around the locked unit but that there is no one to redirect them while the two nurse aides are providing care and the nurse is passing medications or doing treatments. She stated that there were supposed to be three nurse aides, but one of them was called away to do something else. She explained that when she is providing care for a resident in the MIU she has to take her time and sometimes it can take up to a half an hour to get someone ready in the morning because she has to be able to explain what she is doing and go slowly or else the residents can get violent with her. Interview with Nurse Aide 3 on April 22, 2026 at 11:08 a.m. revealed that there were supposed to be three nurse aides in the MIU today, however, one of them was pulled to go on a trip with another resident leaving on the two nurse aides for 30 residents. She stated that the residents are pretty much on their own when they are doing care because there is no one else to watch them. She stated they try to take the residents into the common area, but that many of them wander and end up getting into things they should not, or into rooms they should not go in. Interview with the Assistant Director of Nursing on April 22, 2026 at 2:01 p.m. revealed that the residents that reside on the Memory Impaired Unit require special care due to their dementia. Interview with the Nursing Home Administrator on April 22, 2026 at 3:24 p.m. revealed that the facility's staffing is currently out of compliance and according to the current staffing information provided by the Nursing Home Administrator, the facility is unable to meet the necessary nurse aide ratios or the daily PPD (direct nursing care per resident per day). 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters were flushed according to the facility's policy for one of 14 residents reviewed (Resident 4). Findings include:The facility's policy regarding flushing intravenous (IV) catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated April 20, 2026, revealed that flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. All peripheral IV catheters are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer.A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated March 13, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.Physician's orders for Resident 4, dated April 13, 2026, included orders to insert a peripheral IV catheter to administer 1 gram (gm) of Rocephin (an antibiotic) once a day during the evening from April 14 thru April 18, 2026. Review of Resident 4's Medication Administration Records (MAR's) for April 2026 revealed that the resident received 1 gm Rocephin in the evening from April 14 thru April 18, 2026; however, there was no documented evidence that staff flushed the peripheral IV catheter before and after the administration.Interview with the Director of Nursing on April 22, 2026, at 8:49 a.m. confirmed that there was no documented evidence that Resident 4's IV catheter was flushed before and after the medication administration.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for four of 14 residents reviewed (Residents 4, 10, 11, 12). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated March 13, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.Physician's orders for Resident 4 dated November 7 and December 26, 2025, March 14 and April 15, 2026, included orders for the resident to receive 0.2 milligrams (mg) of Clonidine HCl (used to treat high blood pressure) every day in the morning, 20 mg of Lasix (used to treat fluid retention) every day in the morning, 10 mg of Memantine (used to treat memory) two times a day in the morning and evening, 50 mg Metoprolol tartrate (used to treat high blood pressure) two times a day in the morning and evening and 50 mg of Sertraline (used to treat depression) every day in the morning.Interview with Licensed Practical Nurse 1 on April 21, 2026, at 12:44 p.m. revealed that the morning medication administration times were between 6:15 and 10:00 a.m. and as of April 21, 2026, at 12:44 p.m. Resident 4 did not receive her morning medications as ordered by the physician.Interview with the Nursing Home Administrator on April 21, 2026, at 12:54 p.m. confirmed that Resident 4 did not receive her morning medication as ordered by her physician and she should have.A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had diagnoses that included dementia. Nurse Practioner's note for Resident 10, dated April 6, 2026 revealed that the resident had fallen and that staff were to obtain orthostatic blood pressures (blood pressure taken while sitting, then standing, then lying) for three days. There was no documented evidence that staff obtained orthostatic blood pressures for Resident 10 as ordered. A quarterly MDS for Resident 11, dated March 29, 2026, revealed that the resident was cognitively impaired, ambulated independently, had verbal behaviors, and had diagnoses that included dementia. A quarterly MDS assessment for Resident 12, dated March 18, 2026, revealed that the resident was cognitively impaired, ambulated independently, and had diagnoses that included dementia. Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated and she was told that Resident 12 would be seen by psychiatric services in the morning. Nursing note for Resident 11, dated March 16, 2026 revealed that the resident's legal guardian and daughter were notified of the incident with Resident 12 and that Resident 11 would be seen by psychiatric services in the morning. There was no documented evidence that Resident 11 or Resident 12 were seen by psychiatric services after the incident on March 12, 2026 as their families were told would happen. An interview with the Nursing Home Administrator and Clinical Consultant on April 22, 2026 at 4:24 p.m. revealed that the orthostatic blood pressures were not obtained for Resident 10, and Residents 11 and 12 were not seen by psychiatric services and they should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, the facility assessment and clinical records, as well as observations and family and staff interviews, it was determined that the facility failed to provide adequate ongoing activities designed to meet the needs of six of six residents reviewed (Residents 7, 8, 9, 10, 11, 12) who resided in the Memory Impaired Unit (MIU) and had behaviors and/or dementia. Findings include:The facility's policy regarding Dementia Care, dated April 20, 2026 revealed that staff will be trained to provide necessary care and services that are person-centered and reflect the resident's goals, while maximizing the dignity, autonomy, privacy, socialization, independence, choice, and safety of the resident. Staff would be familiar with dementia care approaches and each resident's person-centered care plan. Individualized, non-pharmacological approaches to care will be utilized, including the provision of meaningful life enrichment activities.The facility's assessment, dated April 6, 2026 revealed that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that the Life Enrichment staffing requirements were one full time director and three full time aides.An quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 18, 2026, revealed that the resident was cognitively impaired, was dependent on staff for care needs, and had diagnoses that included dementia (a brain disorder that causes memory loss). The resident's care plan failed to identify the resident's activity preferences.A quarterly MDS assessment for Resident 8, dated March 11, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, was independently ambulatory, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences.A quarterly MDS assessment for Resident 9, dated March 30, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences.A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had diagnoses that included dementia. The resident's care plan, dated March 5, 2026, was not individualized to identify the resident's activity preferences.A quarterly MDS for Resident 11, dated March 29, 2026, revealed that the resident was cognitively impaired, ambulated independently, had verbal behaviors, and had diagnoses that included dementia. The resident's care plan, dated November 11, 2025, indicated that the resident had behaviors and that staff were to provide activities that resembled her prior lifestyle, however, the resident's care plan was not individualized to reflect the resident's prior lifestyle or what she enjoyed to do.A quarterly MDS assessment for Resident 12, dated March 18, 2026, revealed that the resident was cognitively impaired, ambulated independently, and had diagnoses that included dementia. The resident's care plan failed to identify the resident's activity preferences. Observations in the MIU on April 21, 2026 at 11:20 a.m. revealed that there were 14 residents sitting around the tables in the common room. The activity aide was playing music, but was not engaging the residents in any activity. One resident pulled her shirt over her head exposing her breasts multiple times and staff was not always present in the common room to pull the resident's shirt down or cover her up. There were no further activities observed in the MIU on April 21, 2026. Observations in the MIU on April 22, 2026 at 10:00 a.m. revealed that the activity aide brought a coffee cart with donuts into the unit. At 10:20 a.m. the first resident was served a half a donut and a cup of iced tea. At 10:31 a.m. she finished passing donuts and drinks to the residents. There were two residents in the common room that were not offered donuts or drinks. She did not engage any residents in a group activity. Residents were observed wandering aimlessly, getting into the cupboards and drawers around the room, and yelling out. There were no other activities observed in the MIU on April 22, 2026.Observations in the MIU on April 22, 2026 at 10:46 a.m. revealed that there were two residents wandering the unit aimlessly, 11 residents sitting in the common area with no stimulation, and six residents sleeping in the common area.Interview with Family Member 2 on April 21, 2026 at 12:14 p.m. revealed that she visits her mother daily and she has not seen any activities in the MIU for several months. She stated that she has asked that her mother be able to participate in some activities, especially bingo, but that none have been provided. She said she tries to interact with as many residents as she can so that they get some kind of stimulation because she felt bad that they just sit around and do nothing but sleep. She further stated that the activity aide was putting on a show today because she has not done anything in the MIU for months.Interview with Registered Nurse 1 on April 21, 2026 at 12:53 p.m. revealed that there have not been any activities in the MIU for some time. She stated that activities would help some of the residents who have behaviors and keep them from acting out, but she does not have time to do activities with them, nor do the nurse aides. She stated that the MIU might have three nurse aides scheduled, but one is usually pulled to go on appointments and that leaves two nurse aides for 30 residents and they do not have time to do activities.Interview with the Activities Director on April 21, 2026 at 1:36 p.m. revealed that she does not have enough staff to do activities in the MIU currently. She stated that she hopes to hire more staff, but in the mean time there is no one available to provide activities in the MIU and there has not been anyone for at least two months. Interview with the Nursing Home Administrator on April 22, 2026 at 3:24 p.m. revealed that the activity department is currently understaffed and that she is in the process of hiring new staff. She acknowledged that there is a need for activities in the MIU.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of policies, clinical records, and facility grievance forms, as well as staff interviews, it was determined that the facility failed to include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the family's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of 14 residents reviewed (Resident 6).Findings include: The facility's grievance policy, dated April 20, 2026, indicated that the resident had a right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished, the behavior of staff, and other residents and any other concern regarding the resident's stay. Upon receipt of an oral, written, or anonymous grievance submitted by a resident, the Grievance Official would take immediate action to prevent further potential violations of any resident right while the alleged violation was being investigated, if indicated. The Grievance Committee/Grievance Official would complete an investigation of the residents' grievance. This may include a review of the facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Committee. The grievance review would be completed in a reasonable time frame consistent with the type of grievance, but in no event would the review exceed thirty days. Upon completion of the review, the Grievance Official would complete a written grievance decision the included the date the grievance was received, a summary of the statement of the resident's grievance, steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the resident's grievance was confirmed or not confirmed, whether any corrective action was taken or would be taken, and the date the written decision was issued.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 30, 2026, revealed that the resident was moderately cognitively impaired, able to make her needs known, and had a urinary tract infection.A nursing note written by the Case Manager , dated April 15, 2026, at 8:03 a.m. revealed that a voicemail was received from Resident 6's family member to return her call regarding Resident 6. Resident Family Member 6 was upset about being moved from a private room and multiple other things on the 400 wing. It was explained that she would speak with management on this in the morning meeting, and she would return her call.However, there was no documented evidence that Resident Family Member 6's concerns were followed up with, as indicated in the nurse's notes. There was no documented evidence that Resident Family Member 6's complaint/grievance was thoroughly investigated.A review of the Grievance log for April 2026 revealed that there was no grievance investigation regarding Resident Family Member 6's concerns.Interview with the Case Manager on April 22, 2026, at 11:47 a.m. confirmed that she did not make a follow up call to Resident Family Member 6 regarding her concerns.Interview with Social Service on April 22, 2026, at 12:21 p.m. revealed that Resident Family Member 6 had concerns regarding being moved out of a private room and that staff weren't being nice to her. She confirmed that there had been no call to the family and they were very angry.28 Pa. Code 201.29(i) Resident rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information regarding medications upon discharge for one of 14 residents reviewed (Resident 6) who were discharged to home.Findings include:An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 21, 2025, revealed that the resident was cognitively intact, was incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had no current pressure ulcers.An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 30, 2026, revealed that the resident was moderately cognitively impaired, able to make her needs known, and had a urinary tract infection.Physician's orders, dated March 12 and 24, and April 6, 2026, included orders for the resident to receive 650 milligrams (mg) of acetaminophen every six hours as needed, 100 mg of allopurinol (used to treat gout) twice a day, 5 mg of Eliquis (blood thinner) twice day, 10 mg of famotidine (used to treat acid reflux and heartburn) daily, 800 micrograms (mcg) of folic acid (supplement) daily, 24 units of Lantus(insulin glargine) daily, 500 mg of levetiracetam (anti-convulsant medication) twice a day, 25 mcg of levothyroxine (used to treat thyroid disease) daily, a multivitamin daily, 20 mg of nadolol (used to treat heart disease) daily, a sliding scale (amount of insulin based on blood sugar results) of Novolog (insulin) before meals and at bedtime, 50 mg of pregabalin (anti-convulsant medication) daily, 17 grams of polyethylene glycol as needed for constipation, 100 mg of thiamine (vitamin B supplement) daily, 50 mg of tramadol (pain medication) every six as needed, and 550 mg of Xifaxan (antibiotic) twice a day.A nursing note dated April 15, 2026, at 11:12 a.m. revealed the resident's family member was in to take Resident 6 home. The resident was educated on all discharge orders and medications and all belongings and medications including narcotics were sent home with the resident.The discharge instructions for Resident 6, dated April 15, 2026, revealed that the resident was being discharged home and the current list of medications and instructions provided to the resident at the time of discharge on ly included Novolog, Lantus, acetaminophen, and polyethylene glycol. There was no documented evidence that the resident or her family was provided a complete list of current medications and instructions.Interview with the Director of Nursing on April 22, 2026, at 6:07 p.m. confirmed that there was no documented evidence that Resident 6 or her family was provided a complete list of her current medications and instructions.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents with dementia for two of 14 residents reviewed (Residents 8, 12) and failed to develop a comprehensive care plan that included specific and individualized interventions to address the activity preferences of residents residing within the Memory Impaired Unit for 1 of 14 residents reviewed (Resident 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 11, 2026, indicated that the resident was cognitively impaired, required moderate assistance with daily care needs, and had diagnoses that included Dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors). There was no documented evidence that a care plan was developed to address Resident 8's individual care and treatment needs related to her dementia.A quarterly MDS assessment for Resident 12, dated March 18, 2026, indicated that the resident was severely confused, was independent with ambulation, and had diagnoses that included Korsakoff's dementia (a type of brain disorder that causes memory loss, impaired thinking and behaviors). Observations of Resident 12 on April 21, 2026 at 10:22 a.m. revealed that he was walking with Resident 11 with her holding his arm as they walked. Staff redirected them from the exit door and had them sit together at the dining table.Nursing note for Resident 12, dated December 14, 2025 at 5:29 a.m. revealed that Resident 12 was observed talking with Resident 11, holding her hand and kissing her.Nursing note for Resident 12, dated December 14, 2025 at 1:24 p.m. indicated that Resident 12 was wandering the unit with Resident 11 and they were trying to leave the unit.Nurse's note for Resident 12, dated December 29, 2025 indicated that Resident 12 was walking with and holding hands with Resident 11.Nurse's note for Resident 12, dated March 12, 2026 at 7:10 p.m. revealed that he was found in Resident 11's bed next to her with his pants unbuttoned and he was exposed to her. When the facility notified his daughter/POA she was angry because she was previously told that they would be separated.There was no documented evidence that a care plan was developed to address Resident 12's individual care and treatment needs related to his dementia or behaviors. A quarterly MDS assessment for Resident 9, dated March 30, 2026, revealed that the resident was cognitively impaired, required staff assistance for daily care needs, and had diagnoses that included dementia. There was no documented evidence that a care plan was developed to address Resident 9's individual activity preferences, likes, or dislikes.An interview with the Activity Director and Social Services Director on April 22, 2026 at 4:33 p.m. revealed that they were not educated regarding care planning for resident's dementia needs and that is why Resident's 8 and 12 did not have dementia specific care plans or activity care plans.28 Pa. Code 211.11(d) Resident care plans.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the Pennsylvania Nursing Practice Act, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that a registered nurse completed a timely assessment when changes in condition occurred for one of 14 residents reviewed (Resident 8).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 11, 2026, revealed that the resident was cognitively impaired and required assistance from staff for daily care. A nursing note for Resident 8, dated March 29, 2026, at 6:00 p.m. revealed that the resident reported pain in peri area (area of skin and muscle between the genitals and anus) when sitting in chair in dining area. Resident reports she has no pain with laying in bed or walking. During a shower the Licensed Practical Nurse was called in to observe resident's peri area, where resident had previously had a prolapse observed, now the area is very enlarged more than three times any size previously observed. Licensed Practical Nurse reported to supervisor the prolapse and complaints of pain when sitting in a chair. Will monitor and await supervisor's assessment and any changes made by physician. There was no documented evidence that a registered nurse assessed Resident 8's change in condition when she complained of pain. Interview with the Clinical Consultant on April 22, 2026, at 1:21 p.m. confirmed that Resident 8 should have been assessed by a registered nurse and the assessment should have been documented in the resident's medical record.28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from the optometrist for a follow-up appointment for one of 14 residents reviewed (Resident 5).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 31, 2025, revealed that the resident was cognitively intact and required maximum assistance for daily care needs.An optometry (a profession that specializes in caring for your eyes) consult for Resident 5, dated March 21, 2025, revealed that the resident presented for a diabetic eye exam and an evaluation of bilateral cataracts (a progressive eye condition that causes blurred vision) and recommended that the resident returned in six months for a follow up examination. There was no documented evidence that the optometrist recommendation for Resident 5 to return in six months was completed or that the resident's physician disagreed with the optometrist's plan of care.Interview with the Nursing Home Administrator on April 22, 2026, at 3:10 p.m. confirmed that there was no documented evidence that Resident 5 had a follow up appointment completed as recommended by the optometrist.28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on a review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a device for fall prevention was in place as care planned for one of 14 residents reviewed (Resident 10).Findings include:The facility's policy regarding fall prevention and management, dated April 20, 2026, indicated if risks are identified, preventive measures will be put in place as care planned.A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated January 29, 2026, revealed that the resident had severe cognitive impairment, was sometimes understood, rarely/never understand, and had diagnoses that included dementia. Resident 10's care plan, dated March 5, 2026, indicated that the resident utilized a chair alarm while she is in her chair, and for staff to ensure the alarm is always working.Observations of Resident 10 on April 21, 2026, at 11:56 a.m. revealed that she was sitting in her Broda chair (specialized wheel chair) and that there was chair alarm visible. Observations of Resident 10 on April 21, 2026 at 12:27 p.m. revealed that she stood up out of her chair, no alarm sounded, and staff was not aware of her standing.Interview with Registered Nurse 2 on April 21, 2026, at 12:34 p.m. confirmed that Resident 10's chair alarm was not in place, and that it should have been.Interview with the Nursing Home Administrator on April 21, 2026, at 3:50 p.m. confirmed that Resident 10's chair alarm should have been in place.28 Pa. Code 211.10(a) Resident care policies.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for two of 14 residents reviewed (Residents 3, 10). Findings include:The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated April 20, 2026, indicated that when colostomy care was provided and the drainage bag was replaced, staff were to measure the stoma (surgically created opening that connects the intestines to the outside) size using the measuring guide and trace the pattern of the size of the opening on the wafer (adhesive component that attaches to the skin around the stoma) backing and cut the opening to size.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 24, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). A physician's order, dated September 19, 2025, included an order for the colostomy bag and set up to be changed every three days, and the bag to be dated when changed, per the family request.Observations of Resident 3 on April 21, 2026, at 1:15 p.m. with Licensed Practical Nurse 3, revealed that there was no date marked anywhere on her colostomy bag.Interview with Licensed Practical Nurse 3 on April 21, 2026, at 1:15 p.m. confirmed that the colostomy bag was not dated and should have been.A quarterly MDS assessment for Resident 10, dated January 29, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all her daily care needs, and had a colostomy (an opening in the abdomen that allows waste to exit the body).Observations of Resident 10 on April 21, 2026, at 12:35 p.m. revealed that the resident's colostomy bag/site was being changed by Registered Nurse 1. The registered nurse was standing at her medication cart in the common room where she was observed to cut a hole in the ostomy wafer and gathered other materials. Once in the resident's room Registered Nurse 1 cleaned the skin around the stoma, applied skin prep (a barrier applied on skin to be a barrier between the skin and adhesive), and then applied the wafer and attached bag. The wafer was visibly large compared to the stoma. Registered Nurse 1 did not measure the stoma site or apply the wafer close to the stoma.Interview with Registered Nurse 1 on April 21, 2026, at 12:35 p.m. revealed that she did not measure the stoma to cut the wafer and stated she just eyeballs it.Interview with the Director of Nursing on April 21, 2026, at 2:48 p.m. confirmed that staff should measure the stoma to cut the wafer to size. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers per their preferences and plan of care for one of five residents reviewed (Resident 5).Findings include: The facility policy for bathing and showering, dated October 28, 2025, indicated that residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin conditions. The charge nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternative arrangements that suit the resident can be made. If the resident continues to refuse the Charge nurse will document the resident's refusal in the medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 4, 2025, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs including bathing, and had diagnosis that included dementia. A care plan dated July 29, 2024, revealed that the resident preferred showers twice a week on Wednesdays and Saturdays. She may refuse showers at any time, and a bed bath will be provided. A review of the bathing detail report for Resident 5 from December 1, 2025, through January 31, 2026, revealed that she did not receive showers on Saturday December 6, Wednesday December 10, Saturday December13, Wednesday December 17, Saturday December 20, Wednesday December 24, Saturday December 27, Wednesday December 29, 2025, Saturday January 3, Wednesday January 7, Saturday January 10, Saturday January 17, Wednesday January 21, Saturday January 24, and Saturday January 31, 2026. Interview with the Assistant Director of Nursing on February 3, 2026, at 1:06 a.m. confirmed that there is no documented evidence that staff offered Resident 5 showers and that she refused. She confirmed she should have had a shower per her preference. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for two of five residents reviewed (Resident 2 and 4). Findings include: The facility's policy regarding call lights, dated October 28, 2025, indicated that staff members who are alerted of an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 9, 2025, revealed that the resident was alert and oriented, able to make his needs known, required assistance from staff for daily care needs including toileting, hygiene, and transfers and had medical diagnosis that included multiple sclerosis (disease affects the nerves in the brain and spinal cord). Interview with Resident 2 on February 28, 2023, at 1:56 p.m. revealed that he had to wait for an extended period of time for staff to respond to his call bell. A call bell log for January 2026, for Resident 2 revealed that it took staff 19 minutes to respond to his call bell on January 1, 2026. It took staff 21 minutes to respond to his call bell on January 3; 27 minutes to respond on January 11; 19 minutes on January 26; 1 hour on January 27; 41 minutes on January 28; and 18 minutes on January 31, 2026. A call log for February 2026 revealed it took staff 16 minutes to respond to his call bell on February 1 at 8:51 a.m. and 46 minutes on February 1, 2026, at 2:48 p.m. An annual MDS assessment for Resident 4, dated January 6, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs including toileting, hygiene, and transfers and had medical diagnosis that included hemiplegia (severe or complete loss of strength on one side of the body) and hemiparesis (weakness on one side of the body )following a stroke and diabetes. Review of a grievance form for Resident 4 dated December 15, 2025, revealed that the resident stated that he was put into bed on Sunday at about 10:00 p.m. and no one checked on him until around 4:00 a.m. He tried calling the nurses station with his cellphone, but it just rang and rang. Then staff did come in and help him, and they told him they were short staffed. Review of a call bell log for Resident 4 dated December 14, 2025, through December 16, 2025, revealed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time for that call out was one hour and 47 seconds. Interview with Resident 4 on February 3, 2026, at 3.24 p.m. revealed that on the evening of December 14, 2025, it took staff a long time to get him into bed after he made the request. He would sometimes call the front desk to get a faster response than waiting for staff to respond to his call bell, however, that night no one answered the telephone at the front desk. Interview with the Assistant Director of Nursing on February 3, 2026, at 3:22 p.m. revealed that the call bell wait times listed above were excessive and not acceptable, and that she expects the call bells to be answered within five minutes as anyone can answer a call bell. 28 Pa. Code 201.29(j) Resident rights.

Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. The facility's policy regarding CPR, dated February 15, 2021, revealed that staff were to respond appropriately in the event that cardiac resuscitation was warranted. CPR-certified staff were to be present in the facility at all times. Identification of the resident's code status (whether or not CPR is to be performed) was to be maintained/updated in accordance with the facility's policy (see policy below). In the event of a cardiac arrest, after confirming code status, an announcement with location was to be done via overhead intercom. With the announcement, the responsible team, nursing staff and respiratory therapist (where applicable) were to respond. The nursing personnel closest to the emergency cart at the time of the page was responsible for delivering the emergency cart to the announced location. The RN supervisor or respiratory therapist (where applicable) was to be the team leader and give direction to the team members present. The licensed staff on the unit where the code occurred was to report to the location for direction from the RN supervisor. If the cardiac arrest was witnessed, the facility team was to provide basic life support, including initiation of CPR, to residents who requested CPR in their advance directives, have not formulated an advance directive, do not have a valid DNR order, and do not show signs of clinical death. The facility team was responsible for maintaining CPR until the arrival of the paramedics. If the cardiac arrest was unwitnessed, CPR was to be initiated unless a valid DNR was in place, obvious signs of clinical death were present (decomposition, post mortem lividity, post mortem rigidity), and initiating CPR could cause injury or peril to the rescuer. Once initiated, CPR was not to be interrupted or stopped until an order to do so was obtained from the resident's attending physician or the emergency room physician in charge of the paramedics. The facility's policy regarding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon admission, the POLST form was to be reviewed with every resident/responsible party and signed by the attending physician. The POLST form was to be placed in a plastic sleeve and be the second document in the medical record (after the face sheet). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], revealed that the resident had severe cognitive impairment. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's POLST form, dated [DATE], revealed that the form was signed by Resident Family Member 1 and indicated that CPR was to be provided to the resident. A witness statement from Registered Nurse 2, dated [DATE], revealed that she was assisting Licensed Practical Nurse 3 with another resident in her bathroom when they heard a voice calling Licensed Practical Nurse 3's name. The voice stated that Resident 1 was on the floor. The resident they were assisting was at high risk for falls, so she was educated to stay on the toilet until they could return to assist her. Resident 1 was found sitting by the door to her room. She was alert and safe. Resident 1 had her oxygen on, her gown was on and she was covered in stool. Her brief was on, but it was around her thighs. Resident 1 was asking for help and Registered Nurse 2 assessed her for immediate injuries and found none. Resident 1 was unable to say how she got to the floor. Then Licensed Practical Nurse 3 came to assist with the assessment and then asked for assistance with the first resident. Because Resident 1 was uninjured and the first resident was attempting to get off the toilet by herself, therapy staff was asked to go for the help and seek out a nurse supervisor. The nurse on duty was not on the unit at the time. Resident 1 was alert and sitting by the door when they went to assist the other resident on the toilet. Resident 1 was in no respiratory distress, she was just asking for non-specific help. Once the other resident was safely assisted from the toilet to her wheelchair, Resident 1 was reassessed and was found lying on the floor, cyanotic (blue) and not responding. Registered Nurse 1 was now on the unit and was informed that Resident 1 was not breathing but had a faint carotid pulse (a pulse located in your neck area). Registered Nurse 2 asked for a bag valve mask (BVM - a hand-held device commonly used to provide air to patients who are not breathing or not breathing adequately). Resident 1 was rolled on to her back when Licensed Practical Nurse 3 noticed that the resident had agonal respirations (when someone who is not getting enough oxygen is gasping for air). Registered Nurse 2 and Licensed Practical Nurse 3 attempted to get Resident 1 off the floor using a blanket lift, when Registered Nurse 1 suggested that they get the mechanical lift (a device that uses hydraulic power to lift and move a resident) and place the resident into bed. Registered Nurse 2 inquired about the resident's code status, and Registered Nurse 1 went to check the resident's POLST. After not witnessing any respirations and no pulse, Registered Nurse 1 assessed the resident with a stethoscope and heard no pulse/heart beat and no respirations. Resident 1 was cold and cyanotic. Registered Nurse 1 called the resident's death at 9:22 a.m. A witness statement completed by Registered Nurse 1, dated [DATE], revealed that therapy staff came to her while she was walking out of a resident's room on the 200 hall and told her that she was needed in the Memory Impaired Unit (MIU) because someone fell . Upon entering the MIU, Resident 1 was lying on the floor on her right side in the doorway. As she approached the resident, Registered Nurse 2 stuck her head out of a room and said, She was just sitting up. Both Registered Nurse 2 and Licensed Practical Nurse 3 came out of another resident's room and helped to get Resident 1 off the floor. As they rolled the resident onto her back, Registered Nurse 1 stated that the resident was dead. She felt for a pulse and felt none and witnessed no breaths from the resident. Registered Nurse 1 instructed the nurses to get the mechanical lift for the resident, while Registered Nurse 1 got a stethoscope to call the death. Registered Nurse 1 returned to the room and listened for a heart beat and breaths and there were none. She then checked the resident's code status, but being that the resident had already passed, and had been clammy and purple with no breaths or heart beat, she called the resident's death at 9:22 a.m. Interview with Registered Nurse 1 on [DATE], at 1:34 p.m. revealed that when she arrived at Resident 1's location, the resident was purple and looked to be gone. She called out the resident's name and got no response. That is when Registered Nurse 2 said that the resident was just sitting there. She then kneeled down and there were no respirations or pulse. She told Registered Nurse 2 and Licensed Practical Nurse 3 to get the resident back into bed. She went to get a stethoscope and when she returned, she listened for a heart beat and respirations and could not hear any. She called the death at 9:22 a.m. At that time, someone asked about the resident's code status, so she went to look and found that she was a Full Code. When she walked back in, the resident was clearly gone. In her mind, she was thinking that if they were gone gone then you would not start CPR. She confirmed that the resident did not have any rigor mortis. She recalled that her face was purple. Registered Nurse 1 indicated that she was not familiar with dependent lividity. Interview with Registered Nurse 2 on [DATE], at 1:59 p.m. confirmed that when she returned to Resident 1 after assisting Licensed Practical Nurse 3 with the other resident, Resident 1 had no lividity or rigor mortis. At that time, she was unaware of the resident's code status. There was no documented evidence that CPR was provided to Resident 1, in accordance with her advance directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], at 1:05 p.m., the Nursing Home Administrator was informed that the health and safety of Residents 1 was placed in Immediate Jeopardy due to licensed nurses failing to provide CPR in accordance with Resident 1's advanced directive, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted and implemented an immediate action plan to ensure each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy and the clinical signs of irreversible death, to ensure that CPR was provided in accordance with each resident's advanced directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was lifted on [DATE], at 3:45 p.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records and manufacturer's information, as well as staff interviews, it was determined that the facility failed to obtain physician-ordered medication resulting in a medication not being administered as ordered for one of five residents reviewed (Resident 2), which resulted in [MEDICAL CONDITION] activity with a transfer to the hospital for the resident. Findings include: The facility's current policy regarding unavailable medications indicated that the facility was to make every effort to ensure that medications were available to meet the needs of each resident. The pharmacy was to notify nursing staff that the ordered product was unavailable, when it is anticipated that the medication would become available, and suggest alternative, comparable medication that was available. Nursing staff were to notify the attending physician about the situation and explain the circumstances, obtain a new order, cancel/discontinue the order for the non-available medication, and notify the pharmacy about the replacement order. An admission note for Resident 2, dated March 4, 2020, revealed that he arrived from another nursing facility, was alert and oriented to self, and had no complaints of pain or shortness of breath. Physician orders [REDACTED]. physician's orders [REDACTED]. A nursing note for Resident 2, dated March 4, 2020, at 10:09 p.m. revealed that [MEDICATION NAME] was not available in the facility's Omnicell (a secure device used to store and dispense medications with the proper authorization). A nursing note for Resident 2, dated March 5, 2020, at 9:38 a.m. revealed that the CRNP was notified that the resident did not have [MEDICATION NAME] available at that time. The nurse called the pharmacy to have the medication sent stat (sent immediately). A nursing note for Resident 2, dated March 5, 2020, at 11:51 a.m. revealed that [MEDICATION NAME] was not available and was to be sent from the pharmacy. There was no documented evidence that [MEDICATION NAME] arrived stat, and no documented evidence that nursing staff called the CRNP or physician for an order. A nursing note for Resident 2, dated March 5, 2020, at 9:14 p.m. revealed that [MEDICATION NAME] was not available and was to be sent from the pharmacy. There was no documented evidence that [MEDICATION NAME] arrived stat, and no documented evidence that nursing staff called the CRNP or physician for an order. Resident 2's Medication Administration Record [REDACTED]. A nursing note for Resident 2, dated March 6, 2020, at 12:51 a.m. revealed that the registered nurse was called to the unit at 12:30 a.m. Resident 2 was sitting in a chair unresponsive and tremors were noted to all four extremities and his face. The resident was unable to speak, unable to move any extremity, and a small amount of saliva was running out of the resident's mouth. Oxygen saturation (the percentage of oxygen in the blood) was 89-90 percent on room air, and the resident was placed on two liters of oxygen per minute for comfort. The resident's wife asked that he be sent to the emergency room . An interview with the Director of Nursing on July 9, 2020, at 2:33 p.m. confirmed that Resident 2's physician should have been contacted to get an order for [REDACTED]. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for two of 44 residents reviewed (Residents 46, 105), and resulting in the death of Resident 105. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 105, dated (MONTH) 16, (YEAR), revealed that the resident could understand others and was understood, required limited assistance from staff for daily care and extensive assistance for bed mobility, and the resident received [MEDICAL TREATMENT] (mechanical cleansing of the blood, used when the kidneys are not functioning properly) during the assessment review period. The resident's care plan, dated (MONTH) 10, (YEAR), indicated that the resident had septic arthritis (a painful infection in a joint) of her left knee, and staff were to administer medications as ordered, including [MEDICATION NAME] (a medication to treat a variety of fungal and yeast infections). The care plan also included that the resident had Stage V [MEDICAL CONDITION] (advanced stage of kidney disease where the kidneys have lost nearly all their function) and was recently started on [MEDICAL TREATMENT] which she received three times a week. A nursing note for Resident 105, dated (MONTH) 4, (YEAR), revealed that the resident was sent to the hospital for left knee debridement (the removal of damaged tissue or foreign objects from a wound) by the orthopedic physician (a medical specialty that focuses on the diagnosis, correction, prevention, and treatment of [REDACTED]. A nursing note dated (MONTH) 9, (YEAR), revealed that the resident arrived back at the facility via ambulance. Hospital discharge information for Resident 105, dated (MONTH) 9, (YEAR), indicated that the principle [DIAGNOSES REDACTED]. administered on (MONTH) 7, (YEAR). A prescription written by Physician 1 for Resident 105, dated (MONTH) 5, (YEAR), indicated that the resident was to receive 360 mg of [MEDICATION NAME] with each [MEDICAL TREATMENT] treatment on Mondays, Wednesdays, and Fridays for six weeks. Review of [MEDICAL TREATMENT] communication forms for Resident 105, dated (MONTH) 10 through 29, (YEAR), revealed no documented evidence that the [MEDICAL TREATMENT] provider was informed by the facility that the resident was to receive 360 mg of [MEDICATION NAME] with each [MEDICAL TREATMENT] treatment on Mondays, Wednesdays, and Fridays for six weeks, or that the resident received 360 mg of [MEDICATION NAME] during [MEDICAL TREATMENT] treatments. A nursing note for Resident 105, dated (MONTH) 29, (YEAR), at 9:31 a.m. revealed that the nurse was informed by the [MEDICAL TREATMENT] provider that the resident was hypotensive (low blood pressure) at [MEDICAL TREATMENT] that a.m. with a blood pressure of ,[DATE] millimeters of mercury (mmHg) (normal blood pressure is less than ,[DATE] mmHg). The resident had 1.5 liters of fluid and her blood pressure came up to ,[DATE] mmHg. The [MEDICAL TREATMENT] staff told the nurse that the resident was lethargic and unable to open her eyes. The physician's office was called, information was relayed to his nurse, and the nurse was to await a decision from the physician with the next step. A nursing note for Resident 105, dated (MONTH) 29, (YEAR), at 2:05 p.m. and completed by a licensed practical nurse, revealed that the resident returned from [MEDICAL TREATMENT] via ambulance, was lethargic with a slow verbal response to questions, and gave incorrect answers to where she was and what year it was. The resident was typically alert and oriented to person, place, time, and situation. Her blood pressure was ,[DATE] mmHg. The supervisor was in the room doing an assessment and was to notify the physician. A nursing note for Resident 105, dated (MONTH) 29, 2019, at 2:18 p.m. and completed by a registered nurse, revealed that the resident returned from [MEDICAL TREATMENT] after the physician discussed her status with the [MEDICAL TREATMENT] team. The resident was still very somnolent (sleepy; drowsy), thought she was at the hospital, did not know what the year was, and was very difficult to hear. The physician was called, and an order was received to send the resident to the emergency room . A nursing note at 5:31 p.m. revealed that the nurse placed a call to the hospital for an update on the resident's status and was told that the resident was to be admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. The resident received a blood transfusion due to a hemoglobin (protein in red blood cells that transports oxygen) of 7.2 grams per deciliter (gm/dL)(normal range for women is 12.0 to 15.5 mg/dL). A physician's progress notes for Resident 105, dated (MONTH) 30, (YEAR), revealed that the resident was not in the facility. She became hypotensive (low blood pressure) in [MEDICAL TREATMENT], was transferred to the emergency room , and was found to be septic. The physician reviewed the resident's chart and noted that she was to have been on IV [MEDICATION NAME] every 48 hours for six weeks and apparently this was missed by the facility and not ordered or put in the computer. Staff confirmed with the pharmacy that the [MEDICATION NAME] was never ordered. The resident was readmitted to the hospital's ICU. A social services progress notes for Resident 105, dated (MONTH) 4, (YEAR), at 3:54 p.m. recorded as a late entry, revealed that social services was notified that the resident ceased to breathe at the hospital on (MONTH) 2, (YEAR). A physician's progress notes for Resident 105, dated (MONTH) 2, (YEAR), revealed that the resident was recently admitted for [MEDICAL CONDITION] due to [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA-a bacterium that causes infection and is resistant to multiple antibiotics) to her left knee, which she was supposed to be taking [MEDICATION NAME] for at the nursing home. However, it was discovered that the resident never received this treatment following discharge on (MONTH) 9, (YEAR), and she appeared to have tenderness in her left knee. The resident was hypotensive (low blood pressure) in the emergency room so she was given IV fluids, was started on [MEDICATION NAME] (a medication to increase blood pressure) and transferred to the Intensive Care Unit (ICU) for further care. The resident decompensated overnight on (MONTH) 30, (YEAR) and required intubation (placement of a tube into the lungs to assist with breathing) and multiple pressors (medications to maintain a blood pressure) for septic shock. A death certificate for Resident 105, dated (MONTH) 2, (YEAR), revealed that the immediate cause death was [MEDICAL CONDITION] infarction (a [MEDICAL CONDITION]) and a sequential condition which lead to the immediate cause of death [MEDICAL CONDITION]. A hospital discharge summary for Resident 105, dated (MONTH) 20, (YEAR), indicated that she was admitted on (MONTH) 29, (YEAR), [MEDICAL CONDITION] secondary to infection of the left knee. She progressed to multisystem organ failure, after which her family decided to make her comfort measures only, as she would not want heroic measures to sustain her life. She was made comfort measures only and expired on (MONTH) 2, (YEAR). Interview with the Director of Nursing on (MONTH) 8, 2019, at 3:40 p.m. revealed that she could not find a medication error investigation because the incident was before she was hired at the facility. Interview with [MEDICAL TREATMENT] Manager 3 on (MONTH) 11, 2019, at 10:20 a.m. confirmed that Resident 105 received [MEDICAL TREATMENT] at their facility in (YEAR). He indicated that the resident's electronic medical record revealed no documented evidence that the [MEDICAL TREATMENT] center was notified that the resident was to receive 360 mg of [MEDICATION NAME] with each [MEDICAL TREATMENT] treatment on Mondays, Wednesdays, and Fridays for six weeks, and the resident did not receive the [MEDICATION NAME]. A [DIAGNOSES REDACTED]. Hospital discharge physician's orders [REDACTED]. Resident 46's Medication Administration Record [REDACTED] A nursing note for Resident 46, dated (MONTH) 10, 2019, revealed that the resident's family member noticed that the resident was receiving 10 mg of [MEDICATION NAME] instead of 30 mg as ordered by the physician upon discharge from the hospital. The facility's medication error report confirmed that Resident 46 received 10 mg of [MEDICATION NAME] three times a day instead of 30 mg three times a day as ordered by the physician upon admission to the facility. Interview with the Director of Nursing on (MONTH) 8, 2019, at 9:08 a.m. confirmed that the physician's orders [REDACTED]. 28 Pa. Code 211.2(a)(b) Physician services. 28 Pa. Code 211.5(f) Clinical records. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited [DATE]. 28 Pa. Code 211.11(d) Resident care plan. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of nine residents reviewed (Resident 1), resulting in harm to Resident 1 due to a fall that resulted in fractures. Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 15, (YEAR), indicated that all residents in the facility would not be physically, verbally, mentally or sexually abused, or neglected. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 10, (YEAR), revealed that the resident was confused, required extensive assistance from two staff members for transfers and toileting, and was only able to stabilize himself with staff assistance. The resident's care plan, dated (MONTH) 10, (YEAR), revealed that the resident required two staff members, a gait belt, and a wheeled walker for transfers. An incident note for Resident 1, dated (MONTH) 19, (YEAR), at 6:55 a.m. revealed that the resident was sitting on the edge of the bed, was dressed by Nurse Aide 1, and was told to stand while she pulled his pants up. While standing, his knees buckled and he was lowered to the floor by Nurse Aide 1. X-ray reports, dated (MONTH) 21, (YEAR), confirmed that Resident 1 had an impacted [MEDICAL CONDITION] fibular neck (just below the knee) with some displacement (out of alignment), and a comminuted proximal tibial diaphyseal, metaphyseal and former epiphyseal area with a fracture line extending to the spinous process region (closed fractures of the leg). Education records for Nurse Aide 1 revealed that she signed that she received education regarding the facility's gait/transfer belt use on (MONTH) 15, (YEAR), and education regarding the facility's abuse policy and fall prevention policy on (MONTH) 20, (YEAR). A written statement by the Director of Nursing, dated (MONTH) 19, (YEAR), indicated that Nurse Aide 1 did not have the transfer guide with her and did not know Resident 1's transfer status. Nurse Aide 1 further revealed that she did not use a gait belt or a wheeled walker during care, and did not have another aide present to assist with care. An interview with the Nursing Home Administrator on (MONTH) 16, (YEAR), at 12:30 p.m. confirmed that Nurse Aide 1 failed to follow the facility's safe transfer policy and should have followed Resident 1's care plan for transfers during the care she provided on (MONTH) 19, (YEAR). 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/20/17, 3/3/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/20/17, 3/7/17, 3/3/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/20/17, 4/20/17, 3/7/17, 2/21/17, 8/25/16, 4/21/16, 3/3/16.

Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to provide care in a safe manner for one of nine residents reviewed (Resident 1) who was at risk for falls, resulting in a fall with fractures. Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 10, (YEAR), revealed that the resident was confused, required extensive assistance from two staff members for transfers and toileting, and was only able to stabilize himself with staff assistance. The resident's care plan, dated (MONTH) 10, (YEAR), revealed that the resident required two staff members, a gait belt, and a wheeled walker for transfers. An incident note for Resident 1, dated (MONTH) 19, (YEAR), at 6:55 a.m. revealed that the resident was sitting on the edge of the bed, was dressed by Nurse Aide 1, and was told to stand while she pulled his pants up. While standing, his knees buckled and he was lowered to the floor by Nurse Aide 1. X-ray reports, dated (MONTH) 21, (YEAR), confirmed that Resident 1 had an impacted [MEDICAL CONDITION] fibular neck (just below the knee) with some displacement (out of alignment), and a comminuted proximal tibial diaphyseal, metaphyseal and former epiphyseal area with a fracture line extending to the spinous process region (closed fractures of the leg). Education records for Nurse Aide 1 revealed that she signed that she received education regarding the facility's gait/transfer belt use on (MONTH) 15, (YEAR), and education regarding the facility's abuse policy and fall prevention policy on (MONTH) 20, (YEAR). A written statement by the Director of Nursing, dated (MONTH) 19, (YEAR), indicated that Nurse Aide 1 did not have the transfer guide with her and did not know Resident 1's transfer status. Nurse Aide 1 further revealed that she did not use a gait belt or a wheeled walker during care, and did not have another aide present to assist with care. An interview with the Nursing Home Administrator on (MONTH) 16, (YEAR), at 12:30 p.m. confirmed that Nurse Aide 1 failed to follow the Resident 1's care plan for transfers during the care she provided on (MONTH) 19, (YEAR). 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 2/21/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/20/17, 3/3/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/20/17, 3/7/17, 3/3/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/20/17, 4/21/16, 3/3/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/20/17, 4/20/17, 3/7/17, 2/21/17, 8/25/16, 4/21/16, 3/3/16.