Every finding on record at Homewood Living Plum Creek, Inc

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one resident observed on contact precautions (Resident 24) Findings Include: Review of facility policy, titled Isolation-Categories of Transmission-Based Precautions, revised September 2022, revealed in a section labeled, Contact Precautions, instructions for staff and visitors to wear gloves and a disposable gown with entering a resident's room on contact precautions. Review of Resident 24's clinical record revealed diagnoses of Chloridoids difficile (C-diff, a bacterium that causes an infection of the colon) and sepsis (a dangerous reaction to an infection. It causes extensive inflammation throughout your body that can lead to tissue damage, organ failure and even death). Observation of Resident 24's room on December 16, 2025, at 10:25 AM, revealed Resident 24 lying in bed in her room. On the entrance door to Resident 24's room there was a sign indicating that Resident 24 was on contact precautions and that it was required to wash your hands before entering and before leaving Resident 24's room, it was mandatory to wear gloves while in Resident 24's room, and it was mandatory to wear a protective gown while in Resident 24's room. Further observation at that time revealed Employee 5 (Housekeeper) was in Resident 24's room wearing only disposable gloves and a surgical mask, not a protective gown. Employee 5 then exited Resident 24's room and removed her gloves and applied another pair of disposable gloves, without washing her hands, and then started vacuuming the hallway prior to moving onto the next resident's room to clean. Interview with Employee 5 on December 16, 2025, at 10:25 AM, revealed that Employee 5 was aware that Resident 24 was on contact precautions, but Employee 5 thought that meant that she was required to wear disposable gloves and a surgical mask into Resident 24's room.Review of Resident 24's electronic medical record revealed a stool sample that returned a positive result for Chloridoids difficile on December 10, 2025, at 12:56 PM.Review of Resident 24's physician orders revealed an order for Resident 24 to be on contact precautions starting on December 12, 2025, for C-diff. Review of Resident 24's care plan revealed a care plan of, I have C-diff, with an intervention of, Contact Precautions, with a start date of December 12, 2025. Interview with the Director of Nursing on December 17, 2025, at 2:15 PM, revealed that she was aware of the observation of Employee 5 in Resident 24's room and that employee education had been completed to correct the situation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to implement infection control practices to help prevent the development and transmission of infectious diseases for two of two residents on droplet precautions (Resident 46 and 68). Findings include: Review of facility policy, titled Infection Control Policy, last reviewed April 18, 2024, read, in part, Purpose: The objectives of our infection control policies and procedures are to: Prevent and control the spread of communicable/contagious diseases. Establish guidelines to follow in the implementation of transmission-based precautions. It shall be the responsibility of the Administrator and Director of Nursing (DON) through the Quality Improvement committee, to assure that infection control policies and procedures are implemented and followed. Review of facility document, titled Droplet Precautions, posted outside of Resident 46 and 68's rooms, revealed Everyone must clean their hands before entering & leaving room. Make sure their eyes nose and mouth are fully covered before room entry. Remove face protection before room exit. Review of Resident 46's clinical record revealed diagnoses that included influenza (a disease caused by virus infecting the respiratory tract), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Observation on January 21, 2025, at 12:16 PM, revealed Employee 4 (Nurse Aide) was bringing Resident 46's lunch tray into her room, he did not put on eye protection prior to room entry. Review of Resident 68's clinical record revealed diagnoses that included influenza, congestive heart failure, and muscle weakness. Observation on January 22, 2025, at 12:24 PM, revealed Employee 5 (Nurse Aide) was bringing Resident 68's lunch tray into his room. After leaving the room, she disposed of her face shield outside of the room in a trash bin outside of the room. During an interview with the DON on January 23, 2025, at 10:39 AM, she revealed the disposal bin for personal protective equipment (PPE) should have been stored inside Resident 68's room, and she would expect PPE to be worn appropriately by staff. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.12(d)(1)(5) Nursing Services.

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the right to receive services with reasonable accommodation of resident needs for one of 22 residents reviewed (Resident 4), and failed to ensure that resident needs were accommodated regarding call bell accessibility for one of 22 residents reviewed (Residents 87). Findings include: Review of facility policy, titled Call Lights- Answering, last reviewed April 18, 2024, read, in part, Purpose: To identify and respond to the residents needs. Procedure: call bell will be answered timely. When leaving the room, check to see that the call signal will be within the resident's reach. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Observation of Resident 4's room on January 21, 2025, at 1:06 PM, revealed her call light was on above her room. Interview with Resident 4 on January 21, 2025, at 1:10 PM, revealed she needed to use the rest room. Observation in the hallway on January 21, 2025, at 1:14 PM, the surveyor observed Employee 1 (Registered Nurse) enter residents 4's room to administer a medication. The surveyor heard Resident 4 tell Employee 1 she needed to use the restroom, Employee 1 replied, I will let them know. Employee 1 turned off Resident 4's call light and exited the room. Observation on January 21, 2025, at 1:21 PM, the surveyor observed Employee 2 (Nurse Aide) walk past Resident 4's room and Employee 1 in the hallway. Employee 1 did not notify Employee 2 that Resident 4 needed to use the rest room. During an interview with Employee 1 on January 21, 2025, at 1:28 PM, the surveyor inquired if she was going to notify nurse aide staff that Resident 4 needed to use the restroom and if she had turned off Resident 4's call bell. Employee 1 replied that she did notify a nurse aide and turned off Resident 4's call bell. Observation on January 21, 2025, at 1:28 PM, Employee 1 called Employee 3 (Nurse Aide) to ask for assistance for Resident 4. Observation on January 21, 2025, at 1:29 PM, revealed Employee 3 was entering Resident 4's room to provide assistance. Interview with the Director of Nursing (DON) on January 23, 2025, at 10:18 AM, revealed Employee 1 notified Employee 3 that Resident 4 needed assistance after she left the room via their communication devices, but Employee 3 was busy with an emergent situation for another resident, so she was unable to assist Resident 4 at that time and was delayed in assisting her. During a follow-up interview with the DON on January 23, 2025, at 1:11 PM, the surveyor revealed the concern with Employee 1 turning off Resident 4's call bell before her needs were met and lack of prompt response until surveyor inquiry. No further information was provided. Review of Resident 87's clinical record revealed diagnoses that included macular degeneration (a vision impairment resulting from deterioration of the central part of retina, a thin layer at the back of the eye on the inner side), age related nuclear cataract (hardening and cloudy eye lens leading to vision changes), and hypertension (high blood pressure). Observation in Resident 87's room on January 21, 2025, at 10:32 AM, revealed she was in her bed eating breakfast and her call bell was out of reach, laying on her recliner. Review of Resident 87's care plan revealed a focus area of, I have had falls related to poor safety awareness, with a start date of January 17, 2025, with an intervention for please keep my frequently used items within reach, with a start date of January 17, 2025. Interview with the DON on January 23, 2025, at 1:09 PM, revealed she would expect Resident 87's call bell to be in reach. 28 Pa code 201.29(a) Resident Rights 28 Pa Code 211.12(d)(1) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 25 residents reviewed (Resident 49). Findings Include: Review of Resident 49's clinical record revealed diagnoses that included cerebral infarction (occurs when blood flow to the brain is interrupted, causing brain tissue to die) and gastro-esophageal reflux disease (a chronic condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms). Review of Resident 49's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 8, 2024, revealed in Section I6100. Post Traumatic Stress Disorder (PTSD), that Resident 49 has been treated for PTSD in the previous 7 days while a resident. Review of Resident 49's electronic medical record failed to reveal any treatment for PTSD. Review of Resident 49's care plan failed to reveal any care plan for PTSD. Interview with the Director of Nursing on January 22, 2025, at 9:58 AM, revealed that Resident 49's MDS completed on November 8, 2024, was marked in error and that Resident 49 does not have any history of PTSD and an MDS correction will be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for one of 22 residents reviewed (Resident 41). Findings include: Review of Resident 41's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), localized edema (swelling caused due to excess fluid accumulation), and muscle weakness. Interview with Resident 41 on January 21, 2025, at 10:17 AM, revealed he has had issues with fluid retention in his legs. Review of Resident 41's physician orders revealed an order for Tubi grips to bilateral lower extremities (BLE), on AM off HS (evening)- twice a day for edema, with a start date of September 20, 2024. Review of Resident 41's care plan revealed a focus area of, I require limited to extensive assistance with my bathing, grooming, dressing, supervision, and set up with mobility and eating related to CHF and unsteady gait, with an intervention for Tubi grips on AM off HS to BLE, with a start date of October 31, 2024. Observation of Resident 41 on January 21, 2025, at 12:18 PM, revealed he was in bed eating lunch, he had edema to his lower extremities, and his Tubi grips were not in place. Observation of Resident 41 on January 22, 2025, at 10:15 AM, revealed he was in his wheelchair, he had edema to his lower extremities, and his Tubi grips were not in place. Interview with Resident 41 on January 22, 2025, at 12:20 PM, revealed he has not worn Tubi grips to his legs in over a month since he has had a lot off weight loss and his edema has improved. Review of Resident 41's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) revealed his physician order for Tubi grips was signed off that they were in place on January 21 and 22, 2025. During an interview with the Director of Nursing on January 23, 2025, at 10:33 AM, she revealed Resident 41 used to have a lot of edema but it has really gone down, so they changed his physician order on January 22, 2025, to be as needed. She further revealed she would expect the order not to be signed that the Tubi grips were in place when they were not. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure PRN (as needed) orders for anti-psychotic drugs are limited to 14 days for one of five residents reviewed for unnecessary medications (Resident 4). Findings include: Review of facility policy, titled Antipsychotic Medication Use, last reviewed April 18, 2024, read, in part, Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and document the rationale for continued use. The duration of the PRN order will be indicated in the order. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Review of Resident 26's physician orders on January 21, 2025, revealed an order for Seroquel (antipsychotic medication) 25 mg tablet -12.5 mg by mouth twice daily as needed for hallucinations, with a start date of December 31, 2024, and no stop date. During an interview with the Director of Nursing (DON) on January 23, 2025, at 10:14 AM, she revealed Resident 4 was assessed by the practitioner on January 13, 2025, with a noted plan to continue medications as recommended by psych services, and that her next appointment with them was in February. The surveyor revealed the concern with the lack of a 14 day stop date on the PRN Seroquel order and lack of a new order past 14 days. Follow-up interview with the DON on January 23, 2025, at 1:06 PM, she revealed she would expect the facility to comply with the regulation for a stop date of 14 days for PRN antipsychotic medications without exception. 28 Pa code 211.9(a)(1) Pharmacy services 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Resident Assessment Instrument User Manual, clinical record review, and staff interviews, it was determined that the facility failed to complete required Minimum Data Set (MDS) assessments for three of 24 residents reviewed (Residents 9, 27, and 71). Findings include: Review of The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that a discharge assessment must be completed when a resident is admitted to a hospital or other care setting. The manual also indicated that a Death in Facility tracking record must be completed when a resident dies in the facility. Further review revealed that the discharge assessment must be completed within 14 calendar days of discharge and the Death in Facility tracking record must be complete within seven calendar days of the death of the resident. Review of Resident 9's clinical record revealed that she passed away at the facility on November 24, 2023. Review of Resident 27's clinical record revealed that she passed away in the facility on November 12, 2023. Review of Resident 9 and 27's MDS completion and submission records on February 12, 2024, at 2:39 PM, revealed that to date no Death in Facility tracking records had been initiated, completed, or submitted for either Resident. During an interview with the Director of Nursing (DON) on February 14, 2024, at 9:15 AM, she confirmed that MDS assessments should have been completed after Residents 9 and 27 passed away. She also revealed that those submissions would be completed. Review of Resident 71's clinical record revealed that she was transferred out to the hospital on October 9, 2023, and was subsequently admitted . Review of Resident 71's MDS completion and submission records on February 12, 2024, at 2:39 PM, revealed that to date no discharge MDS related to the hospitalization had been initiated, completed, or submitted. During an interview with the DON on February 15, 2024, at 9:37 AM, she confirmed that a discharge MDS should have been completed when Resident 71 was admitted to the hospital. She also revealed that this was corrected. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 23 residents reviewed (Residents 14 and 40). Findings include: Review of Resident 14's July 5, 2023 quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was coded to indicate that Resident 14 experienced a fall with injury since the time the last assessment was completed. Review of Resident 14's clinical record for the indicated timeframe failed to reveal any evidence of a fall. During an interview with the Director of Nursing (DON) on February 14, 2024, at 9:15 AM, she confirmed that Resident 14 did not experience a fall during the timeframe in question and that Resident 14's July 5, 2023, MDS was coded incorrectly for a fall. Review of Resident 40's November 3, 2023, quarterly MDS assessment revealed that it was coded to indicate that she received antipsychotic medication (class of medication primarily used to manage psychosis [when someone loses touch with reality]), and that a dose reduction of this medication was last documented by the physician as being contraindicated on June 5, 2023. Review of geriatric psychiatry consult notes dated September 11, 2023, revealed that on this date the physician documented that a dose reduction of Resident 40's antipsychotic medications was contraindicated. During an interview with the DON on February 14, 2024, at 9:15 AM, she confirmed that Resident 40's November 3, 2023, was incorrectly coded and that a modification had been submitted. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 23 residents reviewed (Residents 18 and 51). Findings include: Review of facility policy, titled Care Planning-Interdisciplinary Team, revised September 2013, revealed, Our facility's care planning/interdisciplinary team is responsible for the development of and individualized comprehensive care plan for each resident. Review of Resident 18's clinical record revealed diagnoses that included muscle weakness (weakness of muscle movements) and fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances). Observation of Resident 18 on February 12, 2024, at 12:14 PM, revealed Resident 18 sitting in a recliner in her room wearing custom made orthotic shoes with built in AFO (an ankle foot orthosis controls the range of motion in your foot and ankle and helps to stabilize its position). Review of Resident 18's care plan on February 12, 2024, failed to reveal any guidance regarding Resident 18's use of orthotic shoes with AFO. Interview with the Director of Nursing (DON) on February 15, 2024, at 9:45 AM, revealed that Resident 18's care plan should have included the shoes with AFO brace. Review of Resident 51's clinical record on February 12, 2024, at approximately 12:00 PM, revealed diagnoses that included cerebral infarction (stroke - sudden loss of blood to a part of the brain which results in damage and death of cells) and dysphagia (difficulty swallowing). Observation of Resident 51 on February 12, 2024, at approximately 10:10 AM, revealed Resident 51 had a disposable tissue partially placed inside Resident 51's mouth. During an interview on February 12, 2024, at approximately 10:20 AM, Employee 1 stated that Resident 51 frequently utilized a tissue placed in his mouth to soak up salivary secretion. During the interview, Employee 1 stated that staff do check Resident 51's mouth during the day to ensure pieces of tissue and/or food are not left in Resident 51's mouth. Review of Resident 51's clinical record revealed Resident 51 was not care planned for placing a tissue in his mouth. During an interview on February 14, 2024, at approximately 1:30 PM, DON confirmed that Resident 51 was known to place tissues in his mouth. DON stated that the family has provided cloth handkerchiefs, but Resident 51 still utilizes disposable tissues at times. During an interview on February 15, 2024, at approximately 9:30 AM, DON provided an updated plan of care for Resident 51 which included the intervention of, I have excessive [secretions]. Staff will encourage me to use handkerchiefs that my family provides but I like to at times use tissues. Staff will monitor my tissue use for concerns. During the staff interview, DON confirmed that the care plan should have reflected Resident 51's use of cloth handkerchief or tissues placed inside the mouth for salivary secretions. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance, in that they had failed to ensure each resident the right to be free from neglect, resulting in harm, for one of three resident records reviewed (Resident 1). Findings Include: Review of the facility's policy, titled Abuse Prevention and Prohibition last revised August 2021, read, [NAME] Retirement Centers s hall provide a safe person-centered environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. The policy defines neglect as failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physicial harm, pain, mental anguish, or emotional distress. Neglect refers to failure through in attentiveness, carelessness, or omission to provide timely, consistent, safety, adequate and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daility living. Activities of Daily Living (ADLs) are defined as activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. Review of the facility's Nurse Aide job description, revised March 23, 2015, summarizes the job as providing the activities of daily living care to residents . The nurse aide essential functions are described as promoting the activity of daily living according to the resident's care plan. Also, Resident lifts and transfers will be done according to the resident's care plan and the Lift Free program. Lift is defined as the procedure used to carry the entire weight of the patient. Review of the facility's lift equipment revealed one type utilized is the Vanderlift. According to documentation, the purpose of the Vanderlift is used to transfer residents from bed to chair, chair to bedside commode and chair to bed. Review of the facility's policy related to the Vanderlift use read At least 2 people must be in attendance when lift is being used. Review of Resident 1's physician orders revealed diagnoses that included repeated falls and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident 1's interdisciplinary plan of care, revealed an ADL care plan that read require extensive assistance with my bathing, grooming, dressing and eating. Vanderlift with transfers to Broda chair. The care plan continues, Vanderlift with 2 [person] assist . According to the facility documentation of an investigation revealed that on August 22, 2023, Resident 1 had fallen from the lift while being transferred from the bed by Employee 1 (Nurse Aide) without assistance from an additional nursing staff individual. The facility investigation revealed Employee 1 reports feeling rushed because she still had resident cares to do and did not ask for help. She did verbalize that she knows the facility policy requires 2 [person] assist for all mechanical lift transfers. Review of Employee 1's statement revealed she made sure it [lift] was hooked up correctly and when I raised her [Resident 1] up out of the bed and off the bed the top right hook twisted in the strap and came off the lift and she slid out of the sling and down on the floor hitting her head on the carpet and the floor and her right elbow also banged on the floor . According to facility documentation, Resident 1 was transferred to the hospital. Review of the hospital discharge summary revealed Resident 1 was diagnosed with subarachnoid hemorrhage (bleeding around the brain), laceration of scalp, and traumatic complete tear of right rotator cuff (muscles and tendons around the shoulder), post fall. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 29, 2023, at 9:17 AM, confirmed the reported event and fall of Resident 1, and subsequent hospitalization with injuries post-fall. A follow-up interview with the NHA and DON, at 1:28 PM, revealed an agreement the actions of Employee 1 met the definition of neglect and Employee 1 did not follow the facility's Lift policy and Resident 1's care plan regarding two-staff assistance with transfers. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after Resident 1's fall with injuries from the Vanderlift on August 22, 2023. On August 22, 2023, the facility began an all staff education on the Vanderlift policy, mandatory two-person transfer. All in-house staff education was completed on August 22, 2023, and additional staff education was completed by August 28, 2023. On August 22, 2023, all lift equipment within and utilized by the facility was inspected for safety by the maintenance staff. On August 22, 2023, the facility began an audit of five transfers to be done weekly. The audits will continue weekly x 4, then biweekly x 2, then monthly x 2. The facility's Maintenance staff will increase inspections of lifts to weekly x 4. The results of the audits will be reviewed as part of the facility's Quality Assurance process. During the abbreviated survey, Resident 1 was observed and her clinical record was reviewed. The facility's audits, education, and an observation of the facility staff use of the Vanderlift were reviewed and no concerns were identified. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance, in that they failed to ensure the resident environment is free from accident hazards, resulting in harm, for one of three resident records reviewed (Resident 1). Findings Include: Review of the facility's document, titled Accident Prevention, dated September 2007, revealed the purpose to ensure each resident will receive adequate supervision and assistive devices to prevent accidents. Also, Implement interventions to reduce hazard and risk. Review of the facility's Nurse Aide job description, revised March 23, 2015, summarizes the job as providing the activities of daily living care to residents . The nurse aide essential functions are described as promoting the activity of daily living according to the resident's care plan. Also, Resident lifts and transfers will be done according to the resident's care plan and the Lift Free program. Lift is defined as the procedure used to carry the entire weight of the patient. Review of the facility's lift equipment revealed one type utilized is the Vanderlift. According to documentation, the purpose of the Vanderlift is used to transfer residents from bed to chair, chair to bedside commode and chair to bed. The facility's policy related to the Vanderlift use read, At least 2 people must be in attendance when lift is being used. Review of Resident 1's physician orders revealed diagnoses that included repeated falls and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident 1's interdisciplinary plan of care, revealed an ADL care plan that read require extensive assistance with my bathing, grooming, dressing and eating. Vanderlift with transfers to Broda chair. The care plan continued, Vanderlift with 2 [person] assist . According to the facility documentation of an investigation revealed that on August 22, 2023, Resident 1 had fallen from the lift while being transferred from the bed by Employee 1 (Nurse Aide) without assistance from an additional nursing staff individual. The facility investigation revealed Employee 1 reports feeling rushed because she still had resident cares to do and did not ask for help. She did verbalize that she knows the facility policy requires 2 [person] assist for all mechanical lift transfers. Review of Employee 1's statement revealed she made sure it [lift] was hooked up correctly and when I raised her [Resident 1] up out of the bed and off the bed the top right hook twisted in the strap and came off the lift and she slid out of the sling and down on the floor hitting her head on the carpet and the floor and her right elbow also banged on the floor . According to facility documentation, Resident 1 was transferred to the hospital. Review of the hospital discharge summary revealed Resident 1 was diagnosed with subarachnoid hemorrhage (bleeding around the brain), laceration of scalp, and traumatic complete tear of right rotator cuff (muscles and tendons around the shoulder), post fall. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 29, 2023, at 9:17 AM, confirmed the reported event and fall of Resident 1, and subsequent hospitalization with injuries post-fall. A follow-up interview with the NHA and DON, at 1:28 PM, revealed an agreement the actions of Employee 1 met the definition of neglect and Employee 1 did not follow the facility's Lift policy and Resident 1's care plan regarding two-staff assistance with transfers. Employee 1 failed to follow the policy and Resident 1's plan of care when transferring the resident with the Vanderlift. The resident subsequently fell from the lift to the floor resulting in a subarachnoid hemorrhage, laceration of scalp, and complete tear of right rotator cuff. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after Resident 1's fall with injuries from the Vanderlift on August 22, 2023. On August 22, 2023, the facility began an all staff education on the Vanderlift policy, mandatory two-person transfer. All in-house staff education was completed on August 22, 2023, and additional staff education was completed by August 28, 2023. On August 22, 2023, all lift equipment within and utilized by the facility was inspected for safety by the maintenance staff. On August 22, 2023, the facility began an audit of five transfers to be done weekly. The audits will continue weekly x 4, then biweekly x 2, then monthly x 2. The facility's Maintenance staff will increase inspections of lifts to weekly x 4. The results of the audits will be reviewed as part of the facility's Quality Assurance process. During the abbreviated survey, Resident 1 was observed and her clinical record was reviewed. The facility's audits, education, and an observation of the facility staff use of the Vanderlift were reviewed and no concerns were identified. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 21 residents reviewed (Residents 34 and 36). Findings include: Review of Resident 34's current physician's orders on March 16, 2023, revealed diagnoses of diabetes (A group of diseases that result in too much sugar in the blood [high blood glucose]) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 34's care plan provided by the facility on March 14, 2023, revealed a care plan problem of: I am Diabetic, with an intervention of: Administer medication per physician orders and monitor for side effects and notify physician as needed. I take Glimepiride and Metformin as ordered. Review of Resident 34's current physician's orders on March 14, 2023, failed to reveal a current physician's order for Glimepiride. Review of Resident 34's discontinued physician's orders on March 16, 2023, revealed a physician's order for Glimepiride 2 mg, with a stop date of June 6, 2022. Interview with the Director of Nursing (DON) on March 15, 2023, at 1:45 PM, revealed that she is aware that the Resident's use of Glimepiride ended on June 6, 2022, and the care plan is being changed to reflect that. Review of Resident 36's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 36's care plan for behavioral concerns noted that she was taking buspirone (medication used to treat anxiety). Review of Resident 36's current physician orders failed to reveal an active order for buspirone. Review of Resident 36's February 2022 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that her order for buspirone was discontinued on March 23, 2022. During an interview with the DON on March 15, 2023, at 2:35 PM, she confirmed that the order for buspirone was discontinued and should not have been on Resident 36's care plan. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 residents reviewed (Residents 33 and 63). Findings include: Review of Resident 33's clinical record revealed diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people). Review of the facility's form, titled Elopement Risk Assessment completed January 3, 2023, revealed the resident assessed to require a secure unit, wanderguard bracelet, frequent monitoring, activities programming and the addition of Resident 33's photo to the wander book/elopement book. Review of Resident's 33's interdisciplinary plan of care reveal a problem area with behavior that reads I have a wanderguard for safety. Also, I would like to remain safe during periods of wandering. Review of Resident 33's interdisciplinary progress notes revealed nursing staff documentation on January 7, 2023, that included wandering in hall . Peeking out the windows and doors. Also, regarding Resident 33's behavior, Wanders throughout unit exit seeking at times or entering other residents rooms . Review of Resident 33's Admission Minimum Data Set (MDS-a tool used to assess all areas specific to the resident), with an Assessment Reference Date (ARD) of January 11, 2023, revealed under Section E: Behavior/0900 Wandering, staff documentation of wandering had not been coded to have occurred within the prior seven days of the ARD. An interview with Employee 1 (Registered Nurse Assessment Coordinator), as well as the Nursing Home Administrator, on March 15, 2023, at 2:26 PM, revealed that the facility staff had not been interviewed regarding the documentation in the interdisciplinary progress notes of Resident 33's episodes of wandering. The interview also revealed the wandering had not been coded as she believed Resident 33 had no purpose. The facility provided no additional explanation or documentation at the conclusion of the survey regarding the MDS coding for Resident 33. Review of Resident 63's clinical record revealed diagnoses that included Alzheimer's disease (brain disorder that gets worse over time characterized by decline in memory, thinking, behavior and social skills) and unspecified mood disorder (group of mental disorders where a disturbance in an individual's mood is the main underlying feature). Review of Resident 63's weight monitoring revealed that she weighed 146.6 pounds on August 1, 2022, and 129 pounds on February 1, 2023. This represented a 12.01% weight loss in six months. Review of Resident 63's February 9, 2023, comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was not coded to indicate that Resident 63 experienced a significant weight loss of more than 10% in the prior six months. During an interview with the Director of Nursing on March 15, 2023, at approximately 10:45 AM, she confirmed that Resident 63's February 9, 2023, MDS should have been coded for a significant weight loss. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the recorded advance directive information accurately reflected the resident's preference for one out of five residents reviewed for advance directives (Resident 13). Findings Include: Review of Resident 13's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for Resident 13 revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment) form dated [DATE] that indicated the resident did not want cardiopulmonary resuscitation (CPR - an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs to maintain circulation when the heart has stopped pumping on its own). Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders were effective [DATE]. Futher review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing on [DATE], at 12:45 PM she confirmed that Resident 13 did have an active order for full code status, but that it was discontinued, and all other resident orders were also reviewed for accuracy of code status. 28 Pa. Code 211.5(f) Clinical records. 28 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 that the resident assessment accurately reflected the resident's status for two of 24 residents reviewed (Residents 72 and 77). Findings include: Review of Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1, dated October 2019, revealed that the instructions for calculating a residents' weight loss (subsection K0300), revealed it included, 10% weight loss in 180 days [sic] Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. Instructions under Steps for Assessment, stated, This item compares the resident's weight in the current observation period with his or her weight at two snapshots in time .At a point closest to 180-days preceding the current weight. Review of Resident 72's clinical record on March 22, 2022, at approximately 1:00 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 72's clinical record revealed that Resident 72's was admitted to the facility on [DATE]. Further review revealed that Resident 72's weight upon admission was recorded as 135 pounds. Resident 72's weight of 135 pounds was entered as the weight on the admission Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial health needs) with an assessment reference date of December 20, 2021. Review of Resident 72's quarterly MDS, with assessment reference date of March 15, 2022, revealed the assessed weight for the MDS was 120 pounds. At the time of the quarterly MDS assessment, Resident 72's assessed weight closest to 180 days from the assessment date was the admission weight of 135 pounds. The weight loss Resident 72 experienced between admission and the Quarterly MDS was 15 pounds or 11%. Review of subsection K0300 - Weight loss: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, revealed it was coded as, 0 - No or unknown. During a staff interview on March 23, 2022, at approximately 2:20 PM, Nursing Home Administrator revealed that after review, Resident 72's quarterly MDS should have been coded to reflect a weight loss of 10% or more in the six months prior to the MDS. Review of Resident 77's electronic health record revealed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 77's March 2022 care plan revealed a care plan addressing a psychosocial well-being problem related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 77's March 8, 2022, comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that this assessment was not coded to indicate that Resident 77 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Nursing Home Administrator on March 23, 2022, at 12:36 PM, she confirmed that Resident 77's dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also revealed that the MDS in question had been corrected. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and staff interviews it was determined that the facility failed to ensure that safety assessments were completed for side rail use for one of six residents reviewed for accident hazards (Resident 41). Findings include: Review of Resident 41's clinical record on March 21, 2022, at approximately 1:30 PM revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During general observations on March 21, 2022, at approximately 10:15 AM, Resident 41 was observed laying in bed. During the observation it was revealed that Resident 41's bed had a bed rail installed in the upright position on the right side of the resident bed (orientation with resident laying in bed on their back). Further review of Resident 41's clinical record on March 22, 2022, at approximately 1:00 PM, it was revealed that Resident 41 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 41's clinical record also revealed no assessment for the use of a bed bed rail. During a staff interview on March 23, 2022, at approximately 12:30 PM, Director of Nursing confirmed that Resident 41 did not have an assessment nor a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa code 211.12(d)(1)(5)Nursing services

Based on record review, interview and policy review it was determined that the facility failed to follow their policy for physician notification for resident change in condition for one of three residents reviewed, (Resident 1). Findings include: A review of the closed clinical record on November 13, 2021, for resident 1 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the closed clinical record revealed resident 1 experienced an unwitnessed fall on October 27, 2021, at 12:30 AM. During the assessment the resident was found to have a two cm (centimeter) diameter raised area above his right eye, a large abrasion on his back, a bruised area on the right elbow, and his whole body was twitching and shaking. Documentation reveals that that resident 1 became unresponsive by the next morning, was changed to comfort measures by the family's choice, and passed away on October 31, 2021. A review of the facility policy titled, Physician Notification Emergent and Non-emergent Notification, last revised January 2020 states, Situations requiring medical direction/guidance immediately will be handled accordingly. Notification will be done immediately when; there is a significant change in a resident's status; an accident or incident with a head injury or any significant injury. All events must be recorded in the electronic health medical record with the times of physician/CRNP/PA or designee notification attempt and response/action taken (ex: transfer). Further review of resident 1's clinical record fails to reveal notification of the physician and the response/action to be taken by staff. The fall investigation report reveals the physician wasn't notified until October 27, 2021, at 07:58 AM. During correspondence with the Director of Nursing on November 15, 2021, she was unable to provide documentation by staff that confirmed physician notification at the time of the fall, or response/action that the physician provided at the time or near the time of the event. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.5(g) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for 1 of 22 residents reviewed (Resident 44).   Findings Include:   Review of Resident 44's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]  muscle mass due to lack of physical activity) Review of Resident 44's significant change MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated August 13, 2020 revealed in Section O0100 k. Hospice Care was not marked to indicate that Resident 44 was receiving Hospice care while a resident of this facility and within the last 14 days. Review of Resident 44's Hospice discharge summary revealed that Resident 44 was receiving Hospice services starting August 15, 2019 until the time she was discharged from Hospice services on August 7, 2020 (6 days prior to the MDS being completed).   Interview with the Director of Nursing on March 25, 2021 at 9:03 AM revealed that Resident 44 had been receiving Hospice services during the specified look back period for the MDS and should have been assessed accordingly. She also revealed that the MDS had been corrected when made aware of the inconsistency. 28 Pa. Code 211.5(f) Clinical records.   28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on observation, policy review, and interview, it was determined that the facility failed to ensure residents were knowledgeable and had access to forms to file an anonymous grievance for eight (8) of eight residents interviewed at the resident group meeting, Residents (13, 26, 38, 64, 77, 80, 85, and 90). Findings include: Observation on the nursing units on (MONTH) 3, 2019, through Hune 6, 2019, failed to reveal the presense of grievance forms visibly available on nursing units in facility. A poster at the front lobby titled, Concerns/Grievances and states if a resident, family member or representative believes that a resident is being mistreated in any way or that a resident's rights have been violated by staff or another resident, a complaint may be filed with the facility's grievance officer. During an interview with the Nursing Home Administrator on (MONTH) 5, 2019, at 9:50 AM, she stated that there are grievance/concern forms located at each nursing station, and that residents or family have ask the nursing staff for them. There was no option to obtain a grievance form to file a grievance anonymously. During the Resident Council meeting on (MONTH) 4, 2019, at 1:12 PM, eight residents (R 13, R 26, R 38, R 64, R 77, R 80, R 85, and R 90) were ask, I f they knew how to file a grievance/concern and they responded, they don't know how to file a grievance, or how to file a grievance/concern anonymously. During an interview with the Nursing Home Administrator on (MONTH) 5, 2019, at 9:50 AM she agreed that grievance/concern reporting forms should be available for residents and family without asking if they desire to remain anonymous. 28 Pa. Code 201.29(i) Resident Rights

Based on review of facility policy, observations, and interviews it was determined that the facility failed to serve the appropriate serving size of an entrée for one of three meals observed, in one of one neighborhoods (lunch meal on Monday, (MONTH) 3rd on the Care South neighborhood). Findings include: Review of facility Menu Policy, review date of (MONTH) (YEAR), revealed portion sizes must be listed for all menus items, all therapeutic diets must be written as an extension of the regular menus. The extension must be completed and/or approved by the clinical dietician. Review of facility Portion Policy, review date (MONTH) (YEAR), revealed each menu will be served in the correct portion size. Regular portion sizes for the noon meal, meat or meat substitutes 3 ounce (oz- a unit of measure), and potato or starch 1/2 cup (a unit of measure). Observation on (MONTH) 3, 2019, at approximately 11:52 AM in the South Central kitchenette it was observed Dietary Aide 1 (DA 1) was serving the slippery ham potpie and utilized a green handled spoodle (a serving spoon). During an interview with DA 1 on (MONTH) 3, 2019, at approximately 12:36 PM DA 1 stated she used a 4 ounce (oz. - a unit of measure) spoodle (a serving spoon) for the slippery ham pot pie. It was revealed that the cook fills the steam table pans with food, and that DA 1 will retrieve the serving utensils, which are stored in the South Central kitchenette. When asked how DA 1 knows what the serving size for a particular item should be, DA 1 stated that there is a book that lists the correct portion size for each menu item served. DA 1 found the binder that contained the extension sheets (a spread sheet that provides information on menu items for the various diets offered and the portion size for each item). DA 1 wasn't able to find the extension sheet for the lunch meal on Monday week 3 (June 3, 2019). During an interview on (MONTH) 3, 2019, at approximately 12:47 PM with Director of Food Service 1 (DFS 1) confirmed that the spoodle (a serving spoon) in the pan of slippery ham pot pie was a 4 ounce spoodle, and that it should have been a 6 ounce spoodle. DFS 1 was able to locate the extension sheet for Monday week 3 noon meal, in the aforementioned binder, and it stated that the serving size for the slippery ham potpie should've been 6 ounces. The extension sheets are an extension of the menu, and were signed by the Registered Dietician. During an interview with the DFS 1 on (MONTH) 3, 2019, at approximately 1:50 PM it was revealed that the portion size for the menu items were documented on the resident tray ticket. Observation of meal ticket for Resident 63 revealed that the slippery ham pot pie, regular portion size, serving should've been 6 ounces. During an interview with the Nursing Home Administrator on (MONTH) 5, 2019, at approximately 2:09 PM it was revealed that the production sheet (a document that contains menu items for a particular meal, the number of portions/servings, and portion size for each item for each dining location) for Monday week 3 lunch meal revealed the serving size for the Slippery Ham Pot Pie was documented as 4 oz. During an interview with DFS 1 on (MONTH) 5, 2019, at approximately 2:09 PM it was revealed that the menu, extension sheets, and meal ticket systems are inter-related. The production sheets are a stand-alone system. It was also revealed that this is the first cycle through the Summer 2019 menu. During an interview with the Nursing Home Administrator on (MONTH) 5, 2019, at approximately 2:30 PM it was revealed that the menu, extension sheets, and production sheets should match. Pa Code 211.6(a)(b) Dietary Services