Every finding on record at Hamilton Arms Center

Based upon review of facility policy and procedure, review of facility documentation and clinical record review, it was determined that the facility failed to ensure residents were free from abuse and neglect resulting in actual harm to one resident (Resident R1). This was identified as past non-compliance for Resident R1.Findings include:Review of facility policy and procedure titled Preventing, Recognizing and Reporting Abuse revealed Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical pain or mental anguish. Further review of this policy revealed Neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safety adequate and appropriate services, treatment of care, including but not limited to nutrition, medication, therapies and activities to daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Review of Resident R1's diagnosis list revealed diagnoses including morbid obesity, Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), muscle weakness, presence of artificial knee joint and cognitive decline. Review of Resident R1's care plan dated November 23, 2022, revealed Resident R1's transfer status as Sit-to-Stand Lift. Review of Resident R1's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) revealed Resident R1 was noted to require substantial maximum assistance needed and used mechanical lift for transfer. Review of facility documentation dated June 27, 2026, revealed CNA (certified nurse aide) reported during transfer to shower chair staff lowered resident to the floor. CNA also reported that the shower chair and misjudged the height of the shower chair during transfer. Further review of facility documentation dated June 27, 2026, revealed statement by Nursing Employee E3; Myself and another aide were trying to transfer resident into shower chair (stand pivot) resident not high enough to reach shower chair seat and chair doesn't lock. Chair slid while trying to lift resident into chair. Had to lower her to the floor. Used lift to put back into bed. Resident c/o [complained of] left knee pain. Notified nurse of incident and complaint of pain. Resident does not do well with stand aide complains of shoulder pain with stand aide. Further review of facility documentation dated June 29, 2026, revealed statement by Employee E4; I was responding to a call bell when I saw the other CNA struggling to transfer resident from the bed to the shower chair. I tried to assist by moving the shower chair closer. We lowered the resident to the floor. I went to get the lift and pad. On Sunday I was reminded not to move a resident that fell/was guided to the floor until assessed. We put the resident on the bed and I think the other CNA reported it to the nurse. Further review of facility documentation revealed Employee E3 failed to use a sit to stand lift for Resident R1 as indicated on Resident R1's care plan. Employee E3 failed to report the fall to the nurse prior to moving the resident from the floor back to the resident's bed and failed to inform administration Resident R1 did not like to utilize the sit-to-stand mechanical lift related to shoulder pain. Review of information submitted to the Department on June 28, 2026, revealed a PB-22 (report of Investigation of Alleged Abuse, Neglect, or Misappropriation of Property) submitted on July 1, 2026, indicated the facility substantiated neglect and terminated Employee E3 on June 29, 2026. Further review of facility documentation dated June 29, 2026, revealed statement by licensed nursing Employee E5 indicating CNA's at 1445 (2:45 p.m.) had reported a fall, after CNA's attempted to transfer resident to a shower chair. Shower chair was reported brakes not secure, resident slid and was lowered to the floor in (their) room. CNAs were then able to transfer resident back to (ihis/her) bed at the time of the incident. Review of Resident R1's clinical progress notes dated June 27, 2026, at 3:55 p.m. revealed called and spoke with [nurse practitioner] to report clinical finding to provider. Provider acknowledges and has ordered a STAT left knee x-ray, ice and elevation to the left knee and PRN [as needed] Lidocaine patch. Orders placed. Also called and spoke with [mobile x-ray] notified of STAT left knee x-ray order and face sheet printed for the x-ray provider. Review of x-ray report dated June 27, 2026, at 6:39 p.m., revealed there is a comminuted fracture of the distal femur in the supracondylar region with separation displacement anteriorly and posteriorly up to 3-4 millimeters. There is soft tissue swelling. Knee prosthesis in place. Acute comminuted distal femoral diaphyseal supracondylar fracture as discussed above with soft tissue swelling. Review of Resident R1's clinical record revealed Resident R1 was transferred to an acute care facility for surgical intervention for the femur fracture on June 27, 2026, at 9:40 p.m. and was readmitted to the facility on [DATE]. Interview with the Nursing Home Administrator and Director of Nursing on July 20, 2026, at 11:00 a.m. confirmed Employee E3 failed to follow Resident R1's care plan by failing to utilize the sit-to-stand mechanical lift for transfers resulting in a fall causing a fractured femur, failed to request additional staff prior to attempting transfer as required, and failed to timely report Resident R1's fall to the nursing supervisor. The facility failed to ensure Employee E3 followed Resident R1's active plan of care prior to transferring Resident R1 from the bed to the shower chair causing a fall resulting in actual harm of a femur fracture of Resident R1. The facility self-identified deficient practice at the time of the incident on June 27, 2026. The facility implemented a corrective action plan of staff education regarding what constitutes abuse and neglect and resident transfers. The facility's immediate action plan included:Ad hoc QAPI meeting on June 28, 2026.On-the-spot in-service was initiated with on-duty staff regarding Registered Nurse notification before moving a resident on the floor, what constitutes a fall, following the plan of care for transfers, any concerns regarding transfer status must be communicated to the nurse and if any concerns with equipment the equipment must immediately be taken out of service and a work order must be initiated.Facility shower chairs were inspected to ensure working brakes.The Staff Development nurse provided education to current staff on the facility Abuse and Neglect policy.Staff who were not educated by July 1, 2026, will not be permitted to work until their education is completed.The Director of Nursing and/or designee will complete audits of observation of resident transfers to ensure the residents' care plans are followed.Audits will be completed daily for one week and weekly for three weeks.The results of all audits will be reviewed by the QAPI committee. The corrective action plan was completed and verified through review of education documentation, interviews, and observation.28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to follow a physician's order for a cardiology (A specialized physician who diagnoses, treats, and prevents diseases of heart and blood vessels) consult for one of the three residents reviewed. (Resident CL1).Findings include: Review of Resident CL1's physician's progress notes dated November 7, 2025, revealed the resident with a chief complaint of Congestive Heart Failure (CHF- When the heart cannot pump enough blood into the body to meet the metabolic needs). The same note revealed a resident with elevated BNP (Brain Natriuretic Peptide - A test to measure hormone produced by the heart to detect or monitor CHF) up to 1000s (normal- generally less than 100 mg/ml). Assessment and plan revealed: BNP elevated, will add extra dose Furosemide (A medication to reduce extra fluid in the body caused by heart failure, liver, and kidney disease); Pt (patient) due for f/u (follow-up) with cardiology, last seen May 2025, placed referral for f/u, discussed with facility and scheduler. Review of Resident CL1's physician's order dated November 6, 2025, revealed an order for Cardiology follow-up. There was no documented evidence indicating that the Cardiology consultation ordered on November 16, 2026, was followed. Review of Resident CL1's nursing progress notes dated December 8, 2025, at 2:04 p.m., revealed: New order per NP (nurse practitioner) f/u Cardiology Dx (diagnosis) CHF. Review of Resident CL1's physician's order dated December 8, 2025, revealed an order for Cardiology follow-up. Review of Resident CL1's physician's progress notes dated December 10, 2025, revealed that the resident continues to complain of shortness of breath, using supplemental O2 (oxygen), and a new medication was ordered. Plan and assessment revealed: CHF. Ordered updated labs for monitoring, will repeat CXR (chest x-ray), last CXR was negative for fluid or acute process. Continue Lasix (Furosemide). Needs f/u with cardiology, discussed this with the facility, which will coordinate scheduling. Review of Resident CL1's nursing progress notes dated December 11, 2025, at 2:48 p.m., revealed that Cardiology has been called twice and messages were left for return call to schedule an appointment, awaiting return call at this time. There was no documented evidence indicating that the Cardiology consult ordered on December 11, 2025, was followed. An interview with the Director of Nursing was conducted on February 25, 2026, at 1:00 p.m. The DON reported that a cardiology consult was scheduled, but the residents could not go due to residents being sick. The DON was unable to provide documented evidence of the above incident. The facility failed to ensure Resident CL1's orders for a cardiology follow-up ordered on November 6, 2025, and December 8, 2025, were followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on review of clinical records and healthcare insurance documents and staff interviews, it was determined that the facility failed to ensure that the resident's appointed representative was notified of a healthcare insurance coverage change for one of three residents reviewed (Resident 1).Findings: Review of Resident 1's diagnosis list includes: Alzheimer's disease (an irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life. Review of Resident 1's Profile Page, revealed that the resident's son [name of the son] was their financial and healthcare POA (A Power of Attorney is a legal document granting an agent authority to act on a principal's behalf regarding financial or medical matters). Review of Resident 1's POA documents signed on March 29. In 2022, confirmed that the residents' son [name] was their financial and care POA. Review of Resident 1's health insurance document, dated October 2025, revealed that the resident's insurance company sent the facility a notification indicating that the resident's current insurance plan is no longer offered. Interview with the Business Manager, Employee E3, was conducted on February 25, 2026, at 11:00 a.m. Employee E3 confirmed that the facility enrolled Resident 1 to new health insurance after a notification from the original insurance indicating that the plan the resident was enrolled in was no longer offered. Employee E3 was not certain of the date the change was made but the new insurance coverage for Resident 1 started on January 26, 2026. Employee E3 further reported that the residents' son, the POA, was notified by the insurance company of the change and questioned the facility why they were not notified. Employee E3 reported that the change was made to ensure that the residents will have coverage (insurance) but did not realize the mistake of not informing the POA first until after the residents' POA called their attention. The POA re-enrolled the residents back to their original insurance with a different plan. An interview with the Nursing Home Administrator on February 25, 2026, at 1:00 p.m., confirmed that the facility enrolled Resident 1 on a different health insurance plan without notifying their POA. The facility failed to ensure residents' appointed representatives were notified of insurance coverage changes. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on review of clinical record, facility documentation, hospital record review and staff interviews, it was determined that the facility failed to ensure one of three residents reviewed received adequate supervision during care resulting in actual harm causing a right ankle nondisplaced fracture for Resident 14. Findings include: Review of Resident 14 's diagnosis revealed diagnoses including other sequelae of cerebral infarction (stroke) and Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side (weakness and paralysis on left side of body).Review of Resident 14 's care plan revealed resident Bed mobility: total assist of one, push on resident's elbow and lower leg to roll.Review of Resident 14 Quarterly Minimum Data Set - (MDS periodic assessments of resident needs) dated May 17, 2025, revealed the resident required one assist for bed mobility and care. Review of Resident 14 clinical record revealed a nursing progress note dated September 3, 2025, at 05:45, indicating CNA (Certified Nursing Assistant) reported to nurse resident fell while providing care, nurse went to the room and observed resident on the floor. Supervisor was notified and responded promptly. Resident was lying on his/her left arm, semi prone position (this is a body position where a person is lying mostly on their stomach but tilted slightly to the side) on the right side of the bed. Resident was assessed and able to tell us where [his/her] pain is and if [he/she] can move- transferred to bed by Hoyer lift (also known as a patient lift is mechanical device designed to safely transfer individuals with limited mobility). Resident sustained visible bump right side of his/her forehead, bruise on his/her left arm and complains of right ankle pain. PRN (as needed or as the situation arises) pain medication was administered and ice pack applied to right ankle. PCP (Primary Care Physician)/POA (Power of Attorney) notified. Neurochecks initiated. Resident transferred to hospital for further evaluation.Review of information dated and submitted by the facility on September 3, 2025, to the Department revealed Resident was assessed and transferred to bed by Hoyer lift. Resident sustained visible hematoma (closed wound where blood collects and fills a space inside your body because it can't flow or drain out) to right side of [his/her] forehead, bruise on [his/her] left arm and complaints of right ankle pain. PRN pain medication was administered and ice pack applied to right ankle/POA notified.Resident transferred to hospital for further evaluation. Due to right ankle pain.Review of hospital records dated September 3, 2025, revealed Resident 14 had an X-ray on right ankle. Results revealed Possible nondisplaced fractures involving the distal fibula (lower end of the thin bone near the ankle) and distal tibia (bottom end of the shin bone near the ankle). Of note there is severe diffuse osteopenia (condition where your bones are weaker than normal due to reduced bone density.Review of facility investigation into the injury revealed a witness statement from Employee 4 obtained on September 3, 2025, at 2:30 am indicating that he/she was doing rounds and rolled resist on his/her side to change him/her. She removed the brief and placed it on the floor and when she looked up to resume care the resident had rolled out of the bed and was on the floor.Interview conducted with the Director of Nursing on September 26, 2025, at 1pm confirmed staff failed to provide Resident 14 with adequate supervision during care resulting in actual harm causing a right ankle nondisplaced fracture.28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations, interviews with staff and record reviews it was determined that the facility failed to ensure food was stored and maintained in accordance with professional standards for food safety for five of five personal refrigerators. Findings Include:Observations of all days of the survey revealed that five residents had personal refrigerators in their rooms. Observations revealed they were no temperature logs or any evidence for monitoring or cleaning refrigerators.Interview with Nursing Home Administrator (NHA) on September 26, 2025, confirmed facility did not have a written policy for personal refrigerators. NHA stated that no education had been provided to residents or their families regarding safe food storage, refrigerator cleaning or temperature monitoring.28 Pa. Code 211.6(c) Dietary Services

Based on review of facility policy, clinical record review, hospice records and staff interview, it was determined that the facility failed to ensure that the clinical record accurately reflected the assessment and treatment of a pressure ulcer for one of four residents reviewed (Resident 14).Review of the facility's policy titled Pressure Ulcers/ Skin Breakdowns-Clinical Protocol last reviewed April 2018 stated that '1.The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a.full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.'Review of Resident 14 physician orders revealed an order started on September 3, 2025 'cleanse open areas on buttocks, apply medihoney and foam dressing, one time a day every 3 days for Wound Care'. Further review of Resident 14 clinical record revealed a skin observation assessment conducted September 3, 2025, at 9:51 p.m. that revealed open area on the coccyx.Review of Resident 14 Hospice care documentation from Caring Hospice Services revealed that weekly monitoring and treatment for a stage 2 pressure ulcer located on the coccyx was conducted on the following days: September 2, 2025; September 10, 2025; September 16, 2025, and September 25, 2025.Review of Resident 14's clinical record did not include facility documentation of the wound assessments, measurements or treatments interventions.Interview with the Director of Nursing on September 26, 2025, at 1 pm confirmed that the facility relied on hospice documentation for the status of pressure ulcer and did not document the wound and treatments in the resident's clinical record.28 Pa. Code: 211.5 (f) Clinical records28 Pa. Code: 211.12 (d) (1) (5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for two of 24 residents reviewed (Residents 6 and 57).Findings include:Review of Resident 6's MDS (Minimum Data Assessment - periodic assessment of resident needs) dated August 9, 2025, under Section N0415 - High Risk Drug Classes: Use and Indication stated that Resident 6 was receiving an anticoagulant (blood thinner).Review of Resident 6 physician orders revealed no evidence that the resident was receiving an anticoagulant.Interview with the Director of Nursing on September 26, 2025, at 1:00 p.m. confirmed that Resident 6's MDS assessment was marked incorrectly.Review of Resident 57's admission MDS assessment (MDS - periodic assessment of resident care needs) dated September 1, 2025, Section N0410 - Medications Received indicated that the resident was receiving an anticoagulant (blood thinner). Further review of the clinical record revealed no evidence that the resident was receiving an anticoagulant.Interview with the Nursing Home Administrator on September 25, 2025, at 12:47 p.m. confirmed that the resident was not receiving an anticoagulant and that the MDS was coded incorrectly.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy and procedure review, observations, clinical documentation review and staff interview it was determined the facility failed to label and store medications appropriately for one of three medication rooms and one of seven medication carts. (2 low and 2 high)Findings include: Review of facility policy and procedure titled Medication Labeling and Storage, revised February 2023, revealed The facility stores all medications and biologicals in locked compartments under proper temperatures.Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medications label includes at a minimum: medications name, prescribed dose, strength, expiration date when applicable, residents name, route of administration and appropriate instructions and precautions. Observation of the 2medication room on the second-floor low side revealed the thermometer in the medication refrigerator was reading 50 degrees Fahrenheit. Review of the Medication Storage Monthly Temperature Log for 2 low medication refrigerator for September 2025 revealed no temperature was logged for September1, 2, 7, 8, 11, 15, 16, 17, 20, 21, 22, and 23. The temperatures logged for September 3, 4,5, 6, 9, 10, 12, 13, 14, 18, 19, and 24 were all for 46 degrees Fahrenheit, the highest temp on the log. Observations of a medication cart on the second-floor high side on September 24, at 11:45 a.m. revealed an opened Lantus (long-acting insulin) administration pen with no date. Interview with Licensed Nursing Employee E5 at the time of the observation confirmed that the Lantus insulin should have been dated when opened. Interview with the Nursing Home Administrator and the Director of Nursing on September 24, 2025 at 12:15 p.m. confirmed opened medications should be dated and the medications refrigerator log was not completed and the high temperature in reading in the refrigerator addressed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review facility policy clinical records, as well as staff interviews, it was determined that the facility failed to follow the physician's orders for blood sugar checks for two of 8 residents reviewed (Residents 8,9), and failed to follow physician's orders for blood pressure checks for one of 8 residents reviewed (Resident 7). Findings include: A facility policy for hypoglycemia (low blood sugar) <70 mg/dL dated, January 2, 2025, revealed that the resident is to be provided with a rapidly absorbed glucose (sugar), the provider notified, stay with the resident and recheck blood sugar in 15 minutes. An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), for Resident 8, dated March 10, 2025, revealed that he was cognitively impaired and had diagnoses that included end stage kidney disease and diabetes mellitus. Physician's orders for Resident 8 dated April 18, 2025, revealed the resident was to receive 40 units of Insulin glargine solution 100 units/milliliter solution subcutaneously in the morning, and the physician was to be notified if the resident's blood sugar was <70 mg/dL or >400 mg/dL. The medication was to be held if the resident's blood sugar <80 mg/dL. A review of the Medication Administration Record (MAR) for Resident 8 for May revealed that on May 10, 2025, the resident's blood sugar was 65 mg/dL, May 15, 2025, the resident's blood sugar was 63 mg/dL, and May 30, 2025, the resident's blood sugar was 59 mg/dL. There was no documented evidence that the physician was notified of Resident 8's blood sugar per physician's order on the above dates, and no documented evidence that the resident was offered a quick absorbing glucose and blood sugar rechecked on the above dates. An admission MDS for Resident 9 dated, April 29, 2025, revealed that the resident was cognitively intact, was understood and understood others and had medical diagnosis of end stage kidney disease and diabetes mellitus. Physician's orders for Resident 9 revealed the resident was to receive blood sugar checks four times a day and notify the physician if blood sugar was >400 or <70 and to initiate hypoglycemic (low blood sugar) protocol. A review of the MAR for Resident 9 for May revealed that at 9:00 a.m. on May 9, 2025, the resident's blood sugar was 69, 9:00 a.m. on May 11, 2025, the blood sugar was 59, at 9:00 p.m. on May 12, and 2025 the blood sugar was 67. A nurses note for Resident 9 on May 12, 2025, at 10:13 p.m. revealed that the resident's blood sugar was 67 mg/dL the resident was offered a milk shake and graham crackers and would be reassessed in 30 minutes. A nurses note for Resident 9 on May 12, 2025, at 11:11 p.m. revealed the resident's blood sugar was rechecked at this time and was 157 mg/dL. There was no documented evidence that the physician was notified of Resident 9's blood sugar per physician's orders, and no documented evidence the resident was offered a quick absorbing glucose and reassessed after 15 minutes on the above dates and times. Interview with the Director of Nursing on June 6, 2025, at 2:30 p.m. confirmed that the resident's were not provided with a quick absorbing glucose reassessed in 15 minutes, and the physician was not notified of the resident's blood sugars and should have been. An Annual MDS assessment for Resident 7 dated May 3, 2025, revealed that the resident was cognitively intact, was understood, and could understand others, and had a medical diagnosis of stroke, coronary artery disease, heart failure, hypertension (high blood pressure), diabetes mellitus, and high cholesterol. Physician's orders for Resident 7 dated August 7, 2024, revealed the resident was to have his blood pressure taken twice a day in the morning and in the evening. A review of the MAR for Resident 7 for May 2025 revealed that there was no documented evidence of a blood pressure taken for resident 7 in the morning on May 7 and 21, 2025, and in the evening on May 23, 2025. Interview with the Director of Nursing on June 5, 2023, at 2:14 p.m. that there were no blood pressures taken for Resident 7 on the above dates and times per physician's orders and there should have been. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records

Based on observations and staff interviews, it was determined the facility failed to establish effective Enhanced Barrier Precautions on two of two nursing floors observed. (First Floor and Second Floor) Findings include: Observation conducted of a resident room on the second-floor nursing unit revealed signage indicating the resident was on Enhanced Barrier Precautions (EBP). Further observation of the resident room failed to reveal evidence of Personal Protective Equipment (PPE) availability. Interview with Employee E3 on September 4, 2024, at 10:10 a.m. revealed Employee E3 was unaware of what PPE should have been utilized in the care of residents on Enhanced Barrier Precautions and further was unaware of where to obtain PPE. Observation of a resident room on the first-floor nursing unit revealed signage indicating the resident was on Enhanced Barrier Precautions. Further observation of the resident room failed to reveal evidence of Personal Protective Equipment (PPE) availability. Interview conducted with Licensed Employee E4 on September 4, 2024, at 10:20 a.m. revealed Licensed Employee E4 was unaware of what PPE should have been utilized in the care of residents on Enhanced Barrier Precautions and further was unaware of where to obtain PPE. Interview conducted with Infection Preventionist Licensed Employee E5 on September 4, 2024, at 11:00 a.m. revealed staff was educated on the use of PPE for EBP residents. Interview conducted with the Nursing Home Administrator on September 6, 2024, at 11:00 a.m. confirmed staff should be aware of the location and use of PPE for EBP residents. 28 Pa. Code 211.12(a)(b)(c)(d)(1)(2)(3)(5) Nursing Services

Based on clinical record review and interviews, it was determined the facility failed to investigate an allegation of abuse for one of 18 residents reviewed (Resident 13). Findings include: Review of Resident 13's clinical progress notes dated July 31, 2024, revealed SSD [social services department] and PT [physical therapy] met with resident for a 48 hour meeting. Resident states he ambulates with a cane and rollator at home. There are 10 steps to enter the apartment building and 13 steps to enter his room. Resident does not have any family that can assist with care, only a significant other that he stays with but isn't involved with providing care. Resident would like to return home with [Home Health] services when the time comes to return home. Resident stated the care could be better as the nursing staff can be grouchy at times. Resident states CNAs are rough when repositioning him and he would like a slower transfer to alleviate pain and anxiousness. SSD contacted resident's daughter to relay all the information discussed during the meeting. [daughter] requested she be emergency contact #1 instead of resident's significant other/roommate. SSD made the change per [daughter's] request. Interview with the Nursing Home Administrator on September 5, 2024, at 9:00 a.m. revealed a grievance form was completed by Social Services regarding Resident 13's allegation but no abuse investigation was conducted. Interview with the Nursing Home Administrator on September 6, 2024, at 9:30 a.m. confirmed an abuse investigation should have been conducted and the abuse allegation should have been reported to the State Agency. 28 Pa. Code 201.18(a)(b)(1)(2)(3) Management

Based on resident and staff interviews and clinical record review, it was determined that the facility failed to clarify and implement physician's orders for one of 18 residents reviewed (Resident 14). Findings include: Interview conducted with Resident 14 on September 4, 2024, at 9:40 a.m. revealed the resident had issues with frequent constipation. Review of Resident 14's active physician ' s orders as of September 6, 2024, revealed the following orders: A physician's order dated August 8, 2024, for Colace 100 milligrams (mg) every 24 hours as needed for constipation. A physician's order dated February 24, 2024, for Dulcolax suppository for no bowel movement for 24 hours after administration of Milk of Magnesia. A physician's order dated August 8, 2024, for Polyethylene Glycol Powder - Give 17 grams by mouth every 24 hours as needed for constipation. A physician's order dated August 9, 2024, for Senna Plus 8.6-50 mg - Give 1 tablet by mouth as needed for constipation at bedtime. Further review of Resident 14's physician orders failed to reveal an order for Milk of Magnesia or clarification as to when each of the other medications should be administered for the resident's constipation. Review of Resident 14's clinical record revealed a GI (gastrointestinal) consult dated August 20, 2024, with recommendations including Senna 8.6 mg daily as needed for constipation if no bowel movement in 2-3 days and to take the Dulcolax suppository as needed if no results from the Senna. Review of Resident 14's progress notes revealed a nurse's note dated August 21, 2024, acknowledging the recommendations from the GI consult. Further review of Resident 14's clinical record failed to reveal the resident's attending physician was made aware of the recommendations. Interview with the Nursing Home Administrator and Director of Nursing on September 6, 2024, at 2:05 p.m. confirmed the facility failed to clarify Resident 14's physician's orders and implement recommendations from the GI consult. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interviews it was determined the facility failed to accurately complete Minimum Data Set (MDS) assessments for two of 18 residents reviewed (Resident 13 and Resident 57). Findings include: Review of Resident 13's Admission Nutrition Evaluation dated July 31, 2024, revealed Resident 13 does have h/o [history of] wt [weight] loss, 6 percent in 4 months. Review of Resident 13's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated August 3, 2024, indicated Resident 13 had a significant weight loss of 5 percent or more in the last month or loss of 10 percent or more in last 6 months. Review of Resident 13's clinical record indicated Resident 13 had a history of weight loss prior to admission; however, it was not a significant weight loss as described in the MDS. Interview with the Nursing Home Administrator on September 6, 2024, at 10:00 a.m. confirmed Resident 13 did not have a significant weight loss prior to admission and therefore should not have been identified on the MDS with a significant weight loss. Review of Resident 57's clinical record revealed a physician's order dated October 23, 2023, for hospice (end of life care). Review of Resident 57's quarterly MDS dated [DATE], revealed under Section O - Special Treatments, Procedures, Programs, that the resident was not marked as receiving hospice services. Interview with the Nursing Home Administrator and Director of Nursing on September 6, 2024, at 1:05 p.m. confirmed Resident 57's MDS assessment should have indicated the resident was receiving hospice services. 28 Pa. Code 211.5(a)(b)(f) Clinical Records

Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-coverage (NOMNC) for one resident and failed to provide Advanced Beneficiary Notice of Non-coverage (ABN) for three of three residents reviewed (Resident 18, Resident 191, Resident 192). Findings include: Review of facility documentation for three residents revealed a Notification of Medicare Non-Coverage (NOMNC) was not provided to Resident 192. Review of facility documentation for three residents revealed Advanced Beneficiary Notice of Non-Coverage (ABN) was not provided to Resident 18, Resident 191, and Resident 192. Interview with the Nursing Home Administrator on September 6, 2024, at 9:00 a.m. confirmed that Resident 192 did not receive a NOMNC and Resident 18, Resident 191 and Resident 192 did not receive ABN notification. 28 Pa. Code 201.18(a)(b)(1) Management

Based on resident interview, clinical record review and staff interview, it was determined that the facility failed to ensure dental services were timely provided for one of 18 residents reviewed (Resident 44). Findings include: Interview with Resident 44 on September 4, 2024, at 2:00 p.m. revealed that the resident is missing fillings and would like to have teeth pulled. Resident also indicated that food gets stuck in the holes in teeth. Review of Resident 44's clinical record revealed that the resident's responsible party had authorized Direct Mobile Dental Services (contracted dental provider at the facility) on May 17, 2023, to perform an annual dental exam, necessary x-rays, and cleanings. Further review of the clinical record revealed no evidence the resident was seen for an annual exam or to address the resident's dental concerns. Interview with the Director of Nursing on September 6, 2024, at 2:00 p.m. confirmed that there was no evidence that a dental exam had been completed. 28 Pa. Code: 211.15(a) Dental services

Based on clinical record review and interview, it was determined the facility failed to report an allegation of abuse for one of 18 residents reviewed (Resident 13). Findings include: Review of Resident 13's clinical progress notes dated July 31, 2024, revealed SSD [social services department] and PT [physical therapy] met with resident for a 48 hour meeting. Resident states he ambulates with a cane and rollator at home. There are 10 steps to enter the apartment building and 13 steps to enter his room. Resident does not have any family that can assist with care, only a significant other that he stays with but isn't involved with providing care. Resident would like to return home with [Home Health] services when the time comes to return home. Resident stated the care could be better as the nursing staff can be grouchy at times. Resident states CNAs are rough when repositioning him and he would like a slower transfer to alleviate pain and anxiousness. SSD contacted resident's daughter to relay all the information discussed during the meeting. [daughter] requested she be emergency contact #1 instead of resident's significant other/roommate. SSD made the change per [daughter's] request. Interview with the Nursing Home Administrator on September 5, 2024, at 9:00 a.m. revealed that a grievance form was completed by Social Services regarding Resident 13's allegation but no abuse investigation was conducted. The interview further revealed the allegation of abuse was also not reported to the State Agency. Interview with the Nursing Home Administrator on September 6, 2024, at 9:30 a.m. confirmed an abuse investigation should have been conducted and the abuse allegation should have been reported to the State Agency. 28 Pa. Code 201.18(a)(b)(1)(2)(3) Management

Based on clinical record review, staff and resident interviews it was determined that [NAME] Arms Center failed to provide appropriate preparation of the resident prior to transfer and discharge for one of one resident reviewed (Resident R3). Findings include: Interview conducted on July 12, 2024 at approximately 5:20 p.m. with Resident R3 revealed concern and frustration with lack of details regarding anticipated discharge to home on July 13, 2024. Resident expressed frustration with lack of knowledge regarding durable medical equipment needed to be able to function in home such as wheelchair, bedside commode and hospital bed. Review of Resident R3's clinical record revealed resident was admitted on [DATE] with diagnoses including but not limited to following: Diabetes Mellitus (the body has high sugar levels for prolonged periods of time); Surgical amputation of leg, Hyptension (high blood pressure), Chronic Kidney Disease, and Atrial Fibrillation (rapid and irregular beating of the atrial chambers of the heart). Review of Resident R3's clinical record included a Medicare cut letter indicated skilled nursing services paid by Humana (contractor for Medicare) would terminate on July 12, 2024. Review of Resident R3's clinical record revealed a discharge planning summary assessment dated [DATE]. Further review of the discharge summary failed to reveal appointment or contact information for primary care physician. Additional review of same document failed to reveal home health agency or durable equipment agency name and contact information. Review of Resident R3's clinical record including progress notes failed to reveal discharge planning details of follow up appointments with primary care physician, home health agency contacted and providing follow up care, or durable medical equipment requested and delivery information for the scheduled discharge of Resident R3. Interview with Director of Nursing on July 12, 2024 at approximately 6:30 p.m. when the above information was conveyed. The facility failed to ensure appropriate tranfer and discharge preparation for Resident R3. 28 Pa Code 211.16(a) Social Services

Based upon observation, it was determined the facility failed to adequately label and store medication on two of three medication carts observed (second floor - low cart and second floor - long hall cart). Findings include: Observation of the medication cart labeled Second floor - low on October 5, 2023 at 1:00 p.m. revealed one unopened and unrefrigerated Novolog Insulin (medication used to treat high blood sugar levels) Pen; one opened and undated Lantus Insulin Pen and one opened and undated vial of Novolog insulin. Observation of the medication cart labeled Second floor - long hall on October 5, 2023 at 1:15 p.m. revealed one opened and undated Lantus Insulin pen and one unopened and unrefrigerated Humalog insulin pen. The above information was conveyed to the Director of Nursing on October 6, 2023 at 11:00 a.m. The facility failed to properly store and label medications. 28 Pa. Code 211.12(a)(d)(1)(2)(5) Nursing Services

Based upon review of facility policies and procedures and observation, it was determined the facility failed to provide appropriate infection control and failed to follow appropriate transmission-based precautions during medication administration and food delivery for two of two nursing units (first floor nursing unit and second floor nursing unit). Findings include: Review of facility policy and procedure titled Administering Medications revealed Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of facility policy and procedure titled Isolation - Categories of Transmission Based Precautions - Droplet Precautions - revealed Masks will be worn when entering the room. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. Observation of medication administration on October 4, 2023, at 8:30 a.m. revealed Licensed Employee E3 administer medication to three residents. Two of the three residents were on Transmission Based Precautions for COVID-19. Observation of Licensed Employee E3 on October 4, 2023, at 8:31 a.m. revealed Licensed Employee E3 administer medications to Resident 57. After administration, Licensed Employee E3 did not wash hands or utilize hand sanitizer. Observation of Licensed Employee E3 on October 4, 2023, at 8:40 a.m. revealed Licensed Employee E3 administer medications to Resident 82. Resident 82 is on transmission-based precautions for COVID-19. Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 82 and did not wash hands or utilize hand sanitizer after administering the medications. Observation of Licensed Employee E3 on October 4, 2023, at 8:46 a.m. revealed Licensed Employee E3 administer medications to Resident 72. Resident 72 is on transmission-based precautions for COVID-19. Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 72 and did not wash hands or utilize hand sanitizer after administering the medications. Licensed Employee E3 then proceeded to prepare medications for the next resident scheduled to receive medications. Observations conducted at approximately 12:33 p.m. on October 4, 2023, on the first floor during food delivery revealed lapses in infection control procedures. Dietary staff was observed delivering food to a resident in room [ROOM NUMBER], who was under droplet precautions due to testing positive for COVID-19, without wearing gloves. Dietary staff left room [ROOM NUMBER] without removing her personal protective equipment (PPE) and neglected to wash her hands. She then entered room [ROOM NUMBER], which housed another resident under droplet precautions, without using gloves. Afterward, she exited room [ROOM NUMBER], donned a pair of gloves, and returned to room [ROOM NUMBER]. At 12:34, the dietary staff exited room [ROOM NUMBER], removed all PPE, and disposed of it in the appropriate trash receptacle. Dietary staff failed to wash her hands before handling two food trays, which she handed over to another staff member for delivery to residents who were not under droplet precautions. The dietary staff left the floor before an interview could be conducted. Surveyor asked E4 RN the name of the dietary staff member, E4 did not recognize the dietary staff member and could not provide the surveyor with her name. The dietary staff member was not observed in the facility for the remainder of the survey. An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 4, 2023, at approximately 1:13 p.m., revealed administration were aware of staff members failing to adhere to droplet precautions on the first floor. Administration reported corrective actions were underway, including staff reeducation. The facility failed to provide appropriate infection control measures during the administration of medications and food delivery. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician orders regarding breakfast during dialysis days for one of two residents reviewed (Resident 34) and monitor weights for one out of 24 residents reviewed (Resident 48). Findings include: Review of Resident 34's diagnosis list revealed an active diagnosis of Chronic Kidney Disease Stage 5 (kidneys have lost the ability to filter waste from an individual's blood). Review of Resident 34's orders revealed an active order for 'Dialysis (blood purifying treatment given when kidney function is not optimum.) days/times: Tuesday/Thursday/Saturday with a start date of August 7, 2023. Review of Resident 34's clinical record revealed an active order for Early breakfast due to dialysis schedule with a start date of August 7, 2023. Further review of Resident 34's clinical record revealed a care plan intervention of DIALYSIS: Specify appointment days Tuesday-Thursday-Saturday. Have ready to leave by 5:00am. Dialysis bag meals with an implementation date of August 5, 2023. Review of Resident 34's clinical record revealed a progress note dated August 26, 2023 at 6:22 a.m. stating Resident left for dialysis this AM not having received breakfast. Multiple calls made down to the kitchen with no answer. RN Supervisor made aware and called kitchen, spoke with staff and was told kitchen staff would bring up a breakfast for resident, though nothing came up and resident left for dialysis. Interview conducted with the Director of Nursing (DON) on October 4, 2023, at approximately 11:15 a.m. confirmed that Resident 34 did not receive breakfast on August 26, 2023 prior to leaving for dialysis. Resident 48 was admitted to the facility on [DATE], with the diagnosis of congestive heart failure (Congestive heart failure (CHF) is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time). Review of the Physician orders for daily weights on July 20, 2023, and state to notify the physician if the resident gains two to three pounds overnight or 5 pounds in one week to monitor for fluid retention (CHF). Further clinical record review revealed Resident 48's weight on August 17, 2023, was 171 and on August 18, it was 175.2 (an increase of 4.5 pounds). There was no documentation that the physician was notified. On August 23, a weight of 175 pounds was recorded on August 24 it was 177 lbs. (an increase of 2 pounds) was recorded with no further documentation that the physician was notified. On September 1, 2023, the resident weight was 174.4 pounds on September 2, a weight of 177.8 (an increase of 3.4 pounds) was recorded. No further documentation that the physician was notified. On September 7, 2023, a weight of 180 pounds was recorded and is a 5.6-pound increase. No further notes stating the physician was notified of this increase. Review of the clinical record revealed a nursing note for September 10, 2023, that Resident 48 was requesting an as needed aerosol treatment for complaints of cough/shortness of breath. Resident was tolerating treatment when resident's eyes closed and slumped over in bed. Provided physical stimuli, tapping on feet, rubbing chest . Call was placed to 911. Review of hospital records dated September 10, 2023, revealed the resident presented in the emergency room with a cough and shortness of breath. Resident 48 was given Lasix and diuresised (the increase of urine production) 16 pounds. An interview with the Director of Nursing on October 6, 2023, at 9:30 a.m. revealed that the facility had no further documentation and failed to notify the physician of the weight gain on all the dates mentioned above. The facility failed to ensure that physician orders were followed regarding early breakfast for Resident 34 and weights being monitored for Resident 48. 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.12(d)(1) Nursing services