Every finding on record at Kadima Rehabilitation & Nursing at Lakeside

Based on a review of clinical records, facility policy, payor source information, and resident and staff interviews, it was determined the facility failed to ensure timely access to necessary dental services for one Medicaid recipient (Resident 17) out of 13 residents reviewed.Findings include:A review of the facility policy titled Dental Services, last reviewed by the facility on March 15, 2026, revealed it is the facility policy to assist residents in obtaining routine and emergency dental care. The policy defined emergency dental services as services needed to treat an episode of acute pain in the teeth or gums, broken or damaged teeth, or any other problem of the oral cavity that requires immediate attention by a dentist. The policy indicated that all actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. A clinical record review revealed Resident 17 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and peripheral vascular disease (condition in which narrowed arteries reduce blood flow to the arms or legs).A review of Resident 17's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2026, revealed that Resident 17 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact).An external dental progress note dated October 27, 2025, documented that Resident 17 had multiple non-restorable teeth (teeth that cannot be repaired) and retained root tips (remaining portions of tooth roots left below or at the gumline after the crown of the tooth is lost). The dental provider documented that Resident 17 agreed to the extraction (removal) of six teeth and retained root tips so dentures could be fabricated.A physician clearance form dated October 28, 2025, documented medical clearance for the extraction of teeth numbered 13, 15, 26, 27, and 28. The physician instructed staff to hold Aspirin 81 milligrams for five days before the procedure.A nursing progress note dated January 15, 2026, documented that external dental services evaluated Resident 17 and that a date for multiple tooth extractions would be scheduled. The note further documented that the physician was notified.A nursing progress note dated May 8, 2026, documented that external dental services completed a routine dental consultation for Resident 17.During an interview on July 21, 2026, at 7:16 PM, Resident 17 stated he had experienced intermittent (occurring on and off) tooth pain for several months related to cracked teeth. He stated he had been waiting for the planned tooth extractions so dentures could be made. Resident 17 further stated that a dental hygienist had cleaned his teeth, but he had not been evaluated by a dentist for several months.A continued clinical record review revealed no documentation that the planned tooth and retained root extractions were completed. The clinical record also lacked documentation explaining the delay in providing the extractions or documenting ongoing efforts to obtain the required dental services. In addition, the record contained no documented evidence that the extractions had been scheduled for a future appointment during the period from the October 27, 2025, dental evaluation through the survey. During an interview on July 23, 2026, at 9:15 AM, the above findings were reviewed with the director of nursing (DON) and nursing home administrator (NHA). The DON and NHA were unable to provide documentation explaining the delay in Resident 17's planned tooth and retained root extractions or documentation demonstrating that the procedure had been scheduled. The facility did not provide documentation that the extractions were scheduled until after the survey team requested supporting information during the week of the survey ending on July 23, 2026. The facility failed to ensure Resident 17 received timely and necessary dental services. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa Code 211.10 (c) Resident care policies.

Based on a review of select facility policies, clinical records, observations, and staff interviews, it was determined the facility failed to implement infection prevention and control practices in accordance with facility policy to prevent the transmission of rhinovirus for two of 13 residents reviewed (Resident 14 and Resident 23) and to implement transmission-based precautions for one of 13 residents reviewed (Resident 23).). Findings include:According to the Centers for Disease Control and Prevention (CDC) guidance titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (Updated September 2024), droplet precautions are intended to prevent transmission of pathogens (organisms that cause disease) spread through close respiratory or mucous membrane contact with respiratory secretions (substances produced by the body such as mucus). Infectious agents for which droplet precautions are indicated include rhinovirus (the most common viral agent in humans and the predominant cause of the common cold). A single patient room is preferred for patients who require droplet precautions. Healthcare personnel wear a mask for close contact with infectious patients; the mask is donned upon room entry. Droplet precautions for rhinovirus should be implemented for the duration of the illness.A review of the facility policy titled Infection Control-Prevention, Control, and Antibiotic Stewardship, last reviewed by the facility on March 15, 2026, revealed it is the facility policy to help prevent the development and transmission of communicable diseases and infections. The policy indicates guidelines for droplet precautions include appropriate signage is placed on the outside of the resident's door when the resident is diagnosed with an infectious droplet agent. Residents may be placed in a private room. If a private room is not available, the resident may be placed in a room with a resident who has an active infection with the same organisms but no other infection (cohorting).A review of the facility policy titled Undiagnosed Respiratory Illness Policy, last reviewed by the facility on March 15, 2026, revealed it is the facility policy to implement evidence-based infection prevention and control practices to minimize the spread of the respiratory viruses, including, but not limited to, rhinovirus and enterovirus. Identified residents will be placed on droplet precautions (infection control measures used to prevent the spread of respiratory illnesses transmitted through respiratory droplets) and encouraged to wear masks outside of the room; signage will be posted at the door requiring visitors and staff to wear masks. Residents testing positive will cohort pending bed availability.A clinical record review revealed Resident 23 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).A review of Resident 23's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2026, revealed that Resident 23 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact).A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).A review of Resident 14's quarterly MDS assessment dated [DATE], revealed that Resident 14 was cognitively intact with a BIMS score of 14.A clinical record review revealed that Residents 14 and 23 shared the same room.A physician's order dated July 21, 2026, at 7:00 AM directed that Resident 23 be placed on droplet precautions every shift due to respiratory symptoms.A nurses' progress note dated July 21, 2026, at 11:40 AM documented the resident representative was notified of Resident 23's respiratory symptoms and new orders for a respiratory panel and droplet precautions.A nurses' progress note dated July 21, 2026, at 5:05 PM documented Resident 23 experienced generalized malaise (a general feeling of illness or discomfort) and a harsh, nonproductive cough.A nurses' progress note dated July 21, 2026, at 5:38 PM documented laboratory testing by polymerase chain reaction (PCR, a laboratory test that detects the genetic material of viruses) identified rhinovirus/enterovirus.A clinical record review revealed no evidence that Resident 14 exhibited signs or symptoms of a respiratory infection and no evidence that Resident 14 tested positive for rhinovirus (the most common viral cause of the common cold) or enterovirus (a group pf viruses that commonly spread from person to person and can cause respiratory illness).An observation on July 21, 2026, at 6:56 PM revealed Resident 23 resting in bed while Resident 14 remained in the shared room watching television. Resident 23 stated she had not been feeling well for several days and reported fatigue and a severe cough. No droplet precaution signage was posted outside the resident room to alert staff or visitors that infection prevention measures were required before entering.Observation on July 22, 2026, at 2:07 PM again revealed no droplet precaution signage posted outside Resident 23's room.During an interview on July 22, 2026, at 2:20 PM, Employee 1, Registered Nurse Supervisor, confirmed no droplet precaution signage had been posted outside Resident 23's room to notify staff or visitors of required infection prevention measures before entering.A progress note dated July 22, 2026, at 4:47 PM documented the facility notified Resident 14's resident representative regarding a rhinovirus outbreak within the facility.A nurses' progress note dated July 22, 2026, at 7:39 PM documented Resident 23 refused a shower because she did not feel well.A nurses' progress note dated July 23, 2026, at 1:21 PM documented Resident 23 continued to experience a slight nonproductive cough, nasal congestion, and weakness, although the resident reported feeling somewhat improved.A clinical record review revealed no documented evidence the facility offered either Resident 23 or Resident 14 a room change after Resident 23 developed respiratory symptoms or tested positive for rhinovirus. The clinical record also contained no documentation the facility discussed the risks of remaining in the same room with an individual who had an active rhinovirus infection.During an interview on July 23, 2026, at 10:30 AM, the Infection Preventionist confirmed facility policy required droplet precaution signage to be posted outside the resident's room so staff and visitors would implement required infection prevention measures before entering. The Infection Preventionist further confirmed facility policy required residents with infectious respiratory pathogens requiring droplet precautions to be isolated or cohorted when appropriate. The Infection Preventionist confirmed the facility did not offer Resident 23 or Resident 14 a room change and did not discuss the risks associated with continuing to share the same room after Resident 23 developed respiratory symptoms or after laboratory testing confirmed rhinovirus/enterovirus.During an interview on July 23, 2026, at 11:30 AM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). 28 Pa Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth , which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Initial tour of the dietary department in the presence of the foodservice director (FSD) on September 2, 2025, at 8:50 AM revealed the following food storage and sanitation concerns with the potential to increase the potential for food-borne illness: Observation of the handwashing area revealed there was no trash can near the sink to dispose of paper towels after washing and drying hands. There were four bags of frozen vegetables and one bag of tater tots on the shelf in the freezer which were not dated. Observation of the dry storage room revealed the metal locking latch of the exit door to the outside was folded back in the door jam which prevented the door from closing. The floor area in front of the door was worn, soiled, and the floor tile was cracked. There was a six inch piece of floor molding missing from the wall to the right of the exit door. Observation of the sink in the janitor closet located in the dietary department revealed the sink contained a plastic bin filled with microfiber cloths, aprons, and a container of cleaning wipes. Interview with the food service director at the time of the observations confirmed the dietary department should be maintained in a sanitary manner and acceptable practices for food storage were to be followed and all food items were to be properly dated to ensure safety and quality and prevent the potential for food contamination and foodborne illness.28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 211.6 (f) Dietary services.

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set for three of 15 residents sampled (Resident 1, Resident 10, & Resident 11).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment to accurately reflect the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior). The Quarterly MDS dated [DATE], documented pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection which makes it difficult to breathe) in Section I2000 (Infections). However, there was no evidence in the clinical record that the resident had pneumonia during the seven-day look-back period. The Registered Nurse Assessment Coordinator (RNAC) confirmed on September 3, 2025, at 10:00AM, that the resident did not have pneumonia during that time and acknowledged the MDS was inaccurate. A clinical records review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease without dyskinesia without mention of fluctuations (progressive movement disorder of the nervous system). The initial MDS dated [DATE], section GG-0115 (section related to functional abilities the ability to perform tasks and activities necessary for daily living) documented no impairment in range of motion (the full movement of a joint). A clinical record review of a Physical Therapy Evaluation and Plan of Treatment (dated June 13, 2025) for Resident 10 documented no impairment in range of motion for both upper and lower extremities. Further clinical record review of an Occupational Therapy Evaluation and Plan of Treatment (dated June 12, 2025) for Resident 10 identified a goal to increase R shoulder flexion (bending of a limb or joint) to 30 degrees by July 3, 2025. The Occupational Therapy Evaluation and Plan of Treatment also noted Resident 10 experienced functional limitations (reported level of difficulty) in range of motion for both one upper and one lower extremity. Observation and interview of Resident 10 on September 2, 2025, at 11:00 AM revealed bilateral hands including fingers and wrists with obvious joint deformities. During observation and interview with this surveyor on September 2, 2025, at 11:00 AM, Resident 10 expressed a desire for devices to help her eat meals such as a fork, spoon, cup. Interview with the Registered Nurse Assessment Coordinator (RNAC) and Director of Rehabilitation on September 3, 2025, at 0856, discussed the above findings. The RNAC and Director of Rehabilitation could not confirm the MDS for Resident 10 had been coded accurately regarding range of motion activities and entered a correction to the MDS during the survey time. A clinical records review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses to include Unspecified dementia, moderate with agitation (a term for a collection of symptoms that can be caused by several disorders that affect the brain). Review of the Quarterly MDS assessment dated [DATE], Section N0450 (antipsychotic medication review), documented that a gradual dose reduction (stepwise lowering of medication) for antipsychotic medication was completed on May 29, 2025. Review of physician orders dated May 20, 2025, documented a new order for a decreased dose of Seroquel (an antipsychotic medication). Review of nursing documentation dated May 20, 2025, confirmed the order was received, and the decreased dose was administered beginning May 20, 2025. During an interview on September 4, 2025, at 11:30 AM, the RNAC stated that the date of May 29, 2025, date was entered on the MDS because it was documented on the psychiatric evaluation form and could not confirm that the MDS was coded accurately. During an interview with the Director of Nursing on September 4, 2025, at 11:28 AM, after review of the MDS coding, the facility was unable to provide documentation to support the accuracy of the MDS coding for Resident 10 and Resident 11.28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 2). Findings included:A review of the facility policy titled Psychotropic Medication Use, last reviewed by the facility on November 27, 2024, revealed it is the facility's policy that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The policy states diagnosis alone does not warrant the use of psychotropic medication. Antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others, and the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions; paranoia; or grandiosity); or behavioral interventions have been attempted and included in the plan of care, except in an emergency. The policy identifies antipsychotic medications as psychotropic drugs.A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 8, 2025, revealed that Resident 2 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates cognition is severely impaired). A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated October 2024 revealed Resident 2 had no episodes of restlessness or verbal aggression during the month. A review of progress notes dated October 1 through October 31, 2024, revealed no documented episodes of maladaptive behaviors (e.g., aggression or restlessness). A psychiatric consultation note dated October 24, 2024, revealed Resident 2 presented for a four-week follow-up related to previous treatment of severe Alzheimer's dementia. The note documented continued resolution of verbal agitation and physical aggression, with persistence of severe cognitive deficits. The note indicated mood irritability had resolved. A review of the MAR/TAR for November 2024 revealed two episodes of restlessness/verbal aggression documented on November 20, 2024. Progress notes dated November 1 through November 23, 2024, revealed no other documented maladaptive behaviors. A note dated November 22, 2024, at 4:57 AM documented Resident 2 was non-compliant with isolation precautions. A progress note dated November 24, 2024, at 10:13 PM revealed Resident 2 was transported to the emergency department after entering another resident's room and becoming physically and verbally abusive toward staff. Resident 2 was striking out, yelling, and making verbal threats stating he was going to kill staff members. A progress note dated November 25, 2024, at 10:21 AM revealed Resident 2 returned from the emergency department in stable condition, calm and cooperative to care with no new orders. The psychiatric certified registered nurse practitioner (CRNP) was made aware and gave a new order to start Rexulti (brexpiprazole, an antipsychotic medication) 0.5 mg daily for 1 week, then increase to 1.0 mg daily. The physician and resident representative were made aware. A physician's order for Rexulti 0.5 mg daily was initiated on November 26, 2024, and increased to 1.0 mg daily on December 3, 2024, for dementia, mild with agitation. A review of progress note documentation dated November 25 through December 3, 2024, revealed no documented evidence that non-pharmacological interventions were attempted prior to the initiation or escalation of Rexulti. Further review revealed no documented evidence that Resident 2's representative was provided sufficient information to make an informed decision regarding the risks and benefits of initiating an antipsychotic medication. Further review of the clinical record from November 25, 2024, through September 4, 2025, revealed Resident 2 continued to display maladaptive behaviors (increased agitation, verbal aggression, physical aggression, and ambulation without safety interventions) on December 4, 5, 6, 13, 29, and 30, 2024; February 20 and 21, 2025; July 14, 18, and 19, 2025; and August 14 and 24, 2025, despite receiving the antipsychotic medication. During an interview on September 4, 2025, at 9:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide documentation that the resident's representative was given information necessary to make an informed decision regarding the initiation of Rexulti, and they were unable to provide evidence that the facility developed or implemented non-pharmacological interventions prior to initiating the medication The facility failed to ensure Resident 2 was free from unnecessary use of a psychotropic medication, resulting in the resident receiving an antipsychotic medication without documented evidence that it was required to treat a specific medical symptom, and without evidence of informed consent or attempted non-drug interventions as required by regulation.28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.2(d)(3) Medical director. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.10(c) Resident care policies.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to develop and implement discharge planning processes that focused on residents' discharge goals for two out of 15 residents sampled (Residents 5 and 9). Findings include: A review of the facility policy titled Discharge planning, last reviewed by the facility on November 27, 2024, revealed the facility's care planning and interdisciplinary team is responsible for the development of the discharge planning process for residents. The policy indicated the resident, resident representative (as applicable), facility department heads, and any other party deemed necessary to the resident's plan of care will meet to determine the resident's goals, establish discharge needs, and set a projected discharge date . A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of an admission Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 18 2025, revealed that Resident 5 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates cognition is intact), and indicated in the Q section (a section used for resident goal setting) that the resident's overall discharge plan was unknown, and that there was no active discharge planning already occurring for the resident to return to the community. A review of Resident 5's care plan, initiated on July 11, 2025, revealed the resident wanted to remain in long-term care at the facility, and to honor their wishes of long-term care. A review of a social service progress note dated July 11, 2025, revealed the resident was admitted for long-term care at the facility. A review of a multidisciplinary care conference note dated July 16, 2025, revealed in the social services summary that the resident's discharge goal was long-term care.During an interview with Resident 5 on September 3, 2025, at 11:00 A.M., the resident expressed a desire to return home to live with his parents as his discharge goal. If returning home was not possible, the resident expressed a preference to transfer to another facility where he had previously been admitted prior to his current admission. Resident 5 stated that these goals had been communicated to the social worker since admission. A review of Resident 5's clinical record revealed no documented evidence that the facility developed a plan of care to reflect the resident's stated goals of either returning home or transferring to another facility. During an interview on September 3, 2025, at 11:25 A.M., with Employee 1, the Social Services Director, confirmed Resident 5 is cognitively intact and able to make his own decisions regarding his care and discharge planning and confirmed Resident 5's care plan did not reflect his wishes to return to the community or transfer to another facility. Employee 1, the Social Services Director, was unable to provide documented evidence that the facility was working with Resident 5 towards a discharge plan that met his goals. Following inquiries made during the survey, Resident 5's care plan was updated on September 3, 2025, to indicate the resident would remain in the facility long-term but wished to return home when medically stable, with possible discharge to be considered if feasible. An interview with the Nursing Home Administrator (NHA) on September 3, 2025, at 11:35 A.M. revealed the information regarding Resident 5's discharge planning goals was reviewed, and the NHA acknowledged that the goals identified by the resident were not reflected in the plan of care. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a mental health condition that combines symptoms of psychosis and a mood disorder, such as depression or bipolar disorder) and epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). A review of a quarterly MDS dated [DATE], revealed that Resident 9 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact). A review of Resident 9's care plan, initiated on June 27, 2025, indicated the resident would remain at the facility on a long-term basis. Interventions included maintaining the resident's wishes to be in long-term care at the facility. However, a progress note dated July 1, 2025, at 12:00 A.M. documented that Resident 9 was admitted to the facility for strengthening after hospitalization. The progress note reflected Resident 9's statement that she intended to regain strength and then return home to live with her daughter. During an interview on September 2, 2025, at 9:40 A.M., Resident 9 explained that she was able to move independently and care for herself. She stated she wished to return home to live with her daughter but expressed there was a problem with discharge planning. Following surveyor inquiries, Resident 9's care plan was updated on September 2, 2025, to indicate she would remain in the facility long-term per the family/power of attorney (POA), though the resident's expressed preference continued to be discharged home with her daughter. During an interview on September 4, 2025, at 12:25 P.M., Employee 1, the Social Services Director, confirmed Resident 9 was cognitively intact and able to make her own decisions regarding care and discharge planning. Employee 1 acknowledged that Resident 9's care plan did not reflect her wishes to return to the community until inquiries were made during the survey and was unable to provide documented evidence that the facility was working toward a discharge plan consistent with her goals. During an interview on September 4, 2025, at 1:00 P.M., the Nursing Home Administrator (NHA) reviewed the information and acknowledged that Resident 9's goals for discharge were not incorporated into the discharge care plan. The NHA was unable to provide evidence that the facility was working with Resident 9 toward a discharge plan that addressed her stated goals. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.18(e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on clinical record review, facility policy review, observations, and staff and resident interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of 15 sampled residents (Resident 10). Findings include: A review of the clinical record revealed Resident 10 was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease without dyskinesia without mention of fluctuations (progressive movement disorder of the nervous system). Further review of the clinical record indicated Resident 10 had a BIMS score of 13 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 13 to 15 suggests the individual is cognitively intact) as of June 17, 2025 A review of nursing progress notes documented two occurrences involving Resident 10's son. On June 14, 2025, and again on July 3, 2025, Resident 10's son demonstrated disruptive and hostile behaviors, including verbal aggression and use of vulgar language toward staff while in the presence of Resident 10. Documentation related to the July 3, 2025, incident indicated that law enforcement intervened, the son was handcuffed, and he was escorted from the facility. Following this event, the son was prohibited from entering the building. A review of the comprehensive care planning policy last reviewed by the facility on November 27, 2024, revealed that the facility will develop an individualized care plan for each resident. The policy further described the goals of care will be established through an evaluation of the resident's present state of physical and emotional health and care plans are revised as information about the resident and resident's condition change. A review of Resident 10's comprehensive care plan, in effect through the survey end date of September 4, 2025, revealed no evidence that Resident 10's psychosocial well-being had been evaluated or addressed in relation to the disruptive behaviors of his son or the subsequent restriction preventing his son from entering the building. During an interview on September 3, 2025, at 9:04 AM, the facility Social Worker confirmed that Resident 10's care plan was not updated to include ongoing assessment of psychosocial needs and related goals following these incidents. In an interview on September 4, 2025, at 11:28 AM, the Director of Nursing acknowledged the facility was unable to provide evidence that Resident 10's care plan had been revised to reflect these events. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.10 (d) Resident care polices.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for 1 resident out of 15 residents sampled (Resident 4). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: AssessmentsClinical problemsCommunications with other health care professionals regarding the patientCommunication with and education of the patient, family, the patient's designated support person, and other third parties. A review of the facility policy titled Anticoagulation Policy, last reviewed by the facility on November 27, 2024, revealed it is the policy of the facility that all residents prescribed anticoagulants (a blood thinner) will be monitored closely for therapeutic effectiveness and potential complications. PT/INR (Prothrombin Time/International Normalized Ratio) is a laboratory blood test used to measure how long it takes blood to clot. The PT measures clotting time, while the INR standardizes the result so it can be interpreted consistently across different labs. Providers use PT/INR values to determine if warfarin is working effectively and safely. If the level is too low, the blood can clot and cause strokes or clots in the legs or lungs. If the level is too high, the resident may experience dangerous bleeding. According to policy, PT/INR levels must be obtained as ordered and results promptly communicated to the provider.Further review revealed that all nursing, medical, and pharmacy staff will follow standardized procedures for administration, lab monitoring, documentation, communication, and education. A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and hydrocephalus (fluid buildup on the brain).A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 4 dated July 11, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 04 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A physician's order dated June 3, 2025, directed warfarin 7 milligrams (mg) by mouth daily at bedtime. A nurse progress note dated June 3, 2025, documented communication with the physician regarding PT/INR results, with instructions to draw the next PT/INR on June 17, 2025. However, a clinical record review revealed no PT/INR was ordered or obtained on June 17, 2025. The June 2025 Medication Administration Record (MAR) showed Resident 4 received Coumadin (brand name for warfarin) 7 mg from June 3 through June 17, 2025. No warfarin was ordered or administered on June 18 or June 19, 2025. On June 20, 2025, at 7:44 A.M., a physician ordered a STAT PT/INR, followed by a one-time dose of 7 mg warfarin at 8:06 A.M., administered at 9:21 A.M. Later that same day, at 12:49 P.M., the physician ordered warfarin 7 mg daily, with a PT/INR to be drawn on June 24, 2025. A nurse progress note dated June 20, 2025, at 8:19 P.M. documented clarification with the on-call provider that Resident 4 should receive the scheduled 7 mg warfarin dose at 9:00 P.M. despite receiving a one-time dose earlier that day, as the resident had missed previous doses. An interview with the Director of Nursing (DON) on September 4, 2025, confirmed that the nurse supervisor had failed to order the June 17, 2025, PT/INR and that Resident 4 had missed two warfarin doses (June 18 and June 19, 2025). Further review of Resident 4's clinical record revealed a physician's order on July 22, 2025, for various labs, including a PT/INR on July 29, 2025. A nurse progress note on July 29, 2025, documented that the PT/INR was drawn that morning. However, the July 2025 MAR revealed no warfarin was ordered or administered on July 29, 2025. A nurse progress note dated July 30, 2025, at 10:20 P.M. documented that the PT/INR results from July 29, 2025, were reviewed with the physician, and new orders were noted. A physician's order at 10:21 P.M. directed a one-time dose of warfarin 6 mg, which was administered at 10:32 P.M. A nurse progress note dated July 31, 2025, at 12:16 P.M. documented that Resident 4's representative was notified of the missed July 29, 2025, warfarin dose; however, there was no evidence the physician was informed of the missed dose. During an interview on September 4, 2025, the DON confirmed that the nurse supervisor had failed to enter the warfarin order from July 29, 2025, and Resident 4 missed a dose of warfarin. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.10 (a)(c) Resident care policies.

Based on staff interview and a review of personnel files and employee credentials, it was determined the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian and failed to ensure frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian the director of food and nutrition services the facility must designate a person to serve as the director of food and nutrition services. (i) The director of food and nutrition services must at a minimum meet one of the following qualifications- (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and must receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. During initial tour of the food and nutrition services department on November 19, 2024, at 8:45 AM the food service director (FSD) stated that he has been the food service director since March 8, 2024. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that the facility has a part-time registered dietitian who works remotely but does not provide any in person oversight to the operation of the department. The FSD noted that there is a regional certified dietary manager who provides some oversight support for the department. Review of the Facility assessment dated [DATE], indicates the facility will have two dietitians or other qualified nutrition professional to serve as the director of food and nutrition services. Review of documentation provided by the facility revealed the facility's onsite registered dietitian's last day of employment was on January 5, 2024. Review of documentation provided by the facility revealed the previous full-time qualified director of food and nutrition service's last day of employment was on March 8, 2024. Interview with the nursing home administrator (NHA) on November 20, 2024, at 9:30 AM confirmed the current part-time registered dietitian who also works for sister facilities works remotely and does not provide in person oversight or consultation to the food and nutrition services department. The NHA confirmed the facility has not had an onsite registered dietitian since January 5, 2024. The NHA confirmed the facility has been without a full-time qualified food and nutrition services director in the absence of a full- time qualified dietitian since March 8, 2024. Refer F692, F804, F838 28 Pa Code 201.18(e)(1)(6) Management.

Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical, nutritional, and rehabilitative needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Further review revealed the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. Review of the Facility Assessment, last reviewed by the facility on September 30, 2024, indicated that the average daily census of the facility is 25-30 residents. The facility's admissions range from 1-2 per week with discharges ranging from 1-2 per week. The facility practices an admission process that revolves around an intensive review of each resident's individual needs before offering admission to the facility. In cases where a less common diagnosis or condition is present, an interdisciplinary review is conducted to ensure the facility can meet the prospective resident's needs. Education on clinical competencies occurs before the resident enters the facility and necessary supplies are made available timely. When a current resident develops a new condition, an immediate interdisciplinary review is conducted, and educational needs are provided. Further review of the Facility Assessment revealed types of resident care provided at the facility are to include Physical Therapy, Occupational Therapy, Speech Therapy, and Respiratory Therapy, and Nutrition services for liberal diets, specialized diets, IV nutrition, tube feeding, cultural dietary needs, assistive devices, and fluid monitoring. The facility assessment stated the facility employs a variety of department heads such as Director of Rehabilitation, Dietitian, and Food Service Director. Additional support staff titles include Physical Therapist, Physical Therapy Assistant, Occupational Therapist, Occupational Therapy Assistant, and Speech Therapist. Review of the facility's Resident Matrix (list of all residents in the facility), dated November 19, 2024, revealed a total census of 26 residents. Of the 26 residents, the Matrix identified one resident (Resident 22) receiving enteral feeding who would require services of a dietitian. Further review of the facility Resident Matrix revealed that at time of survey ending on November 21, 2024, two new residents were admitted to the facility in the last 30 days who would require services by the rehabilitation department. During initial tour of the food and nutrition services department on November 19, 2024, at 8:45 AM, the food service director (FSD) stated that he has been the food service director since March 8, 2024. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that the facility has a part-time registered dietitian who works remotely but does not provide any oversight to the operation of the department. The FSD noted that there is a regional certified dietary manager who provides some oversight support for the department. An interview with the Nursing Home Administrator (NHA) on November 19, 2024, at 2:35 PM, revealed that the facility currently does not have a Director of Rehabilitation, Speech Therapist, Occupational Therapist, or Occupational Therapy Assistant onsite. The NHA revealed that the facility has been without a speech therapist since November 2, 2024, and without an occupational therapist, who was also the Director of Rehabilitation since November 7, 2024. An interview with the NHA on November 20, 2024, at 9:30 AM, revealed since January 5, 2024, the facility has not had an onsite registered dietitian. The NHA confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. The Facility Assessment failed to accurately reflect the current staff employed in the facility to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. An interview with the Nursing Home Administrator on November 21, 2024, at 9:30 AM, confirmed that the facility failed to provide rehabilitative services and nutrition services as outlined in the Facility Assessment. Refer F692, F801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(3) Management

Based on a review of select facility policy and staff interview, it was determined the facility did not have one or more individuals serving as the Infection Preventionist (IP) responsible for the facility's infection prevention plan that worked at least part time at the facility. Findings included: The Centers for Medicare and Medicaid Services regulation S483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP (infection preventionist) must work at least part-time at the facility, physically work onsite in the facility, have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field, cannot be an off-site consultant or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) on November 21, 2024, at 10:00 a.m., it was confirmed that there was currently no designated IP since the previous IP left on October 17, 2024. The NHA further confirmed that the facility did not currently have a qualified staff member credentialed as an infection Preventionist. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on observations, review of clinical records, and resident and staff interview, it was determined the facility failed to provide reasonable accommodation of the needs of a dependent resident for safe wheelchair equipment for one resident out of 14 residents sampled (Resident 180). Findings included: Review of the clinical record revealed that Resident 180 was admitted to the facility on [DATE], with diagnoses to include absence of the right leg below the knee (amputation), and history of falling. Further record review revealed the resident previously underwent a left leg below the knee amputation approximately 4 years ago. Review of Resident 180's care plan dated November 14, 2024, indicated the resident had self-care performance deficits due to impaired mobility with bilateral (both) below the knee amputations, diabetes, peripheral vascular disease, and pain. Interventions included physical and occupational therapy evaluation as ordered, provide two staff member assistance with transfers from the bed to the wheelchair and to transfer to and from the commode using a mechanical full body lift, provide total assistance for toilet use, provide total staff assistance for bathing, provide one staff assistance with dressing and one staff assistance for personal hygiene/oral care. During an interview with Resident 180 on November 19, 2024, at 10:50 AM the resident, with a BIMS score of 10 (BIMS -Brief Interview for Mental Status- a tool to assess cognitive status. A score between 8 to 12 suggests moderate cognitive impairment), reported that he had not been out of bed since he arrived at the facility on November 14, 2024, five days ago. Resident 180 revealed he had not left the room since he was admitted to the facility five days ago. He indicated that he had not been out of bed to attend activities, to dine in the dining room, or attend therapy in the therapy room. The resident stated that had to eat all his meals while in bed because he was not provided with a wheelchair when he entered the facility. Observation of Resident 180's room, conducted at the time of the interview, revealed the resident did not have a wheelchair or specialized seating equipment available for use. Interview with the Director of Nursing (DON) on November 19, 2024, at approximately 11:30 AM indicated that therapy was responsible for assessing Resident 180 for an appropriate wheelchair. Interview with Employee 1 (physical therapist) on November 19, 2024, at 12:40 PM revealed that Resident 180 was evaluated by Physical Therapy on November 15, 2024, and due to his bilateral leg amputations, the resident required front and rear anti-tipper devices (designed to prevent the wheelchair from tipping forward and/or backwards) to be applied to the wheelchair to enhance the stability of the wheelchair. Employee 1 indicated that a maintenance work order was submitted on November 15, 2024. Interview with Employee 2 (nurse aide) on November 19, 2024, at approximately 1:30 PM confirmed that staff were unable to get Resident 180 out of bed for five (5) days because the resident did not have a wheelchair available for use. Review of the facility documentation titled Maintenance Repair Log revealed that a maintenance work order was submitted November 15, 2024, (no time indicated and no name of person filling out report was filled in) to apply front and rear tippers to the wheelchair. The Maintenance Repair Log description of the repairs made and the maintenance signature with time and date were not completed. Interview with the DON on November 21, 2024, at 10:57 AM revealed that Resident 180's wheelchair front and rear anti-tippers were applied by nursing staff on November 19, 2024, after surveyor inquiry, due to maintenance staff not being present in the facility since the work order was submitted on November 15, 2024. Interview with the Nursing Home Administrator and DON on November 21, 2024, at approximately 11:30 AM confirmed the facility failed to provide reasonable accommodations for a resident's positioning needs in a timely manner. 28 Pa. Code 205.75 Supplies 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to assess, evaluate, and monitor nutritional parameters and develop and implement individualized nutritional interventions to maintain nutritional parameters for two residents (Resident 1 and Resident 22) and deter weight loss for one resident (Resident 17) out of 14 residents sampled. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], indicates that the facility will have two dietitians or other qualified nutrition professional to serve as the director of food and nutrition services. During interview with the foodservice director on November 19, 2024, at 8:45 AM the food service director (FSD) stated that he has been the full-time food service director since March 8, 2024, but does not meet the minimum qualifications to be the food and nutrition services supervisor. The FSD stated that he is currently enrolled in a class to become a certified dietary manager. The FSD stated that he does not interact with the facility's part-time registered dietitian who works remotely. The FSD stated that he does visit residents to obtain food preferences which are added to each resident's meal ticket and attends plan of care meetings for residents but does not document in the clinical record. A review of the facility's Nutrition Assessment Policy last reviewed February 2024 indicated that a nutrition assessment shall be completed for each resident admitted to the facility. The dietitian or the dining services manager under the guidance of the dietitian is responsible for developing a nutrition assessment for each resident admitted to the facility. A nutrition assessment will be conducted, and such information will include at least the following information: Weight Height Hematological data Nutritional intake Eating habits Food preferences and dislikes Dietary restrictions Diagnoses Other information deemed necessary and appropriate. Nutrition assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Nutrition assessments will be reviewed quarterly and revised as necessary. A review of the facility Resident Weights policy last reviewed February 2024 indicated weights must be obtained routinely to monitor the parameters of nutrition over time and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for the first 2 days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for 4 weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All monthly weights will be completed by the seventh of the month. Re-weights will be obtained within 72 hours of monthly weight if a weight change greater than 3%. If the weight change is validated, the licensed nurse will notify the physician and dietitian. The licensed nurse will notify the interdisciplinary team for further assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the family will be notified. All weights will be transcribed (including weekly weights and any reweigh) in the resident's medical record. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include diabetes and dementia (chronic persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 1's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 19, 2024, revealed the resident had a BIMS score of 14 (Brief Interview for Mental Status- a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact), weighed 163 pounds, 64 inches tall, had no significant weight loss or weight gain, and was on a regular diet. Further review of the clinical record revealed no documented evidence that a nutritional assessment was completed and documented within 72 hours of Resident 1's admission to the facility to ensure timely assessment, evaluation, and monitoring of nutritional parameters and to establish individualized nutritional goals for Resident 1. A review of the facility's policy entitled Nutrition Assessment for Enteral Feeds, last reviewed February 2024, revealed that a nutrition assessment shall be completed for each resident admitted to the facility with an enteral feed order. The dietician is responsible for developing a nutrition assessment for each resident with enteral feed admitted to the facility. Further review of the policy indicated that a nutrition assessment will be conducted, and include at least the following information: weight, height, hematological data (blood work results), enteral feed order, water flush order, oral intake if any, dietary restrictions if any, diagnoses, and other information deemed necessary and appropriate. Additionally, nutritional assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Nutrition assessment will be reviewed quarterly and revised as necessary. Reviewed of Resident 22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia, (difficulty swallowing), surgical aftercare following surgery for a ruptured appendix, and malnutrition, and required a feeding tube for nutritional support following surgery. Clinical record review revealed that Resident 22 had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for feeding) which was placed during hospitalization . A physician order dated October 29, 2024, was noted for the resident to receive the tube feeding formula of Osmolite 1.5 Cal (liquid feeding administered via feeding tube) at 55 ccs per hour continuous for 24-hours daily with 200 ccs of sterile water every 4 hours for hydration, and a puree diet with thin liquids. A review of Resident 22's admission MDS dated [DATE], revealed the resident had a BIMS score of 14, weighed 167 pounds, 67 inches tall, had no weight loss/weight gain, received nutrition via a feeding tube and a mechanically altered diet. Further review of the MDS indicated that Resident 22 received 25% or less of total calories through enteral feedings and 500mL/day or less of average fluid intake per day through tube feeding despite receiving tube feeding continuously 24 hours a day and routine water flushes of 200mL every 4 hours. Review of Resident 22's weights documented in the clinical record revealed that on October 29, 2024, the resident weighed 167 pounds. On November 4, 2024, the resident weighed 158.6 pounds, an 8.4 pound or 5% weight loss in 6 days. There was no evidence that a reweight was obtained upon admission or that a reweight was obtained after the identified significant weight loss. Upon surveyor request, a weight was obtained on November 21, 2024, and Resident 22 weighed 149.4 pounds, losing an additional 9.2 pounds from the last weight obtained on November 4, 2024. According to documentation, Resident 22 lost a total of 17.6 pounds or 10.5% in 24 days. At time of survey ending on November 21, 2024, there was no evidence that Resident 22's nutritional requirements were evaluated. There was no evidence that Resident 22's significant weight loss was identified and evaluated or that the physician and/or family was made aware. Interview with the nursing home administrator (NHA) on November 20, 2024, at 9:30 AM confirmed that since January 5, 2024, the facility has not had an onsite registered dietitian. The NHA confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. The NHA confirmed that nutritional assessments were to be timely completed to ensure nutritional parameters are maintained to the extent possible for each resident. Review of Resident 17's clinical record revealed the resident was originally admitted to the facility on [DATE], with diagnoses which included dysphagia, and dementia. Further review of the resident's clinical record revealed that the resident was hospitalized on [DATE], and readmitted to the facility on [DATE]. Review of Resident 17's weights documented in the clinical record revealed that a weight was not obtained upon readmission to the facility on [DATE]. The next documented weight was obtained on July 10, 2024, and the resident weighed 122.6 pounds. Review of the clinical record revealed that on August 28, 2024, the resident weighed 112 pounds, a 10.6 pound or 8.6% weight loss in 50 days. A reweight was not obtained until September 1, 2024, which revealed that the resident weighed 111.4, losing an additional 0.6 pounds. Review of the clinical record revealed a dietary note dated September 15, 2024, which identified Resident 17's significant weight loss of August 28, 2024, with recommendations for health shakes twice a day for weight maintenance. There was no evidence that Resident 17's physician and/or responsible party was notified of the significant weight loss. Interview with the Nursing Home Administrator on November 21, 2024, at approximately 11:00 AM confirmed that the facility failed to timely identify Resident 17's significant weight loss and implement the facility's weight policy. Refer F693, F801, F838 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.

Based on observations, clinical record review, and staff interview it was determined that the facility failed to implement physician's orders and provide appropriate treatment and services to one resident out of 14 residents sampled (Resident 22). Findings include: Reviewed of Resident 22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included dysphagia, (difficulty swallowing), surgical aftercare following surgery for a ruptured appendix, and malnutrition. Clinical record review revealed that Resident 22 had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for feeding) which was placed during hospitalization . A physician order dated October 29, 2024, was noted for the resident to receive the tube feeding formula of Osmolite 1.5 Cal (liquid feeding administered via feeding tube) at 55 ccs per hour continuous for 24-hours daily with 200 ccs of sterile water every four hours for hydration, and a puree diet with thin liquids. A physician order dated October 30, 2024, was noted for Resident 22 to receive dysphagia therapy 3 to 5 times a week for 4 weeks to increase toleration to mechanical soft diet. A review of documentation dated November 2, 2024, revealed that Resident 22 continued to receive Osmolite 1.5 Cal at 55mL an hour continuously with 200mL sterile water flush every 4 hours for hydration, a regular diet, puree consistency with thin liquids, and that the resident's appetite remained poor. A review of physician documentation dated November 5, 2024, revealed that Resident 22's spouse inquired about gradually decreasing the tube feeding. According to the documentation, the physician stated, we have to see the patient make some gains with nutrition before we talk about decreasing tube feeding. A review of the resident's clinical record failed to provide evidence that dysphagia therapy intended to advance the resident's diet was provided. Interview with the Nursing Home Administrator on November 20, 2024, at approximately 10:45 a.m., confirmed that there was no evidence the facility provided treatment and services to restore oral eating skills for a resident receiving a tube feeding. Refer F825, F692 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals at safe and palatable temperatures. Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of the facility Food Temperature Recording Policy last reviewed February 2024 indicated that food temperatures will be taken and recorded by the dining services staff prior to the start of each meal service to ensure that food items are at proper temperatures. All hot foods will be served and held at or above 135 degrees Fahrenheit and all cold foods will be held and served at or below 41 degrees Fahrenheit. During a group interview with seven alert and oriented residents on November 20, 2024, at 10:00 AM, all seven residents in attendance (Residents 25, 12, 5, 6, 18, 1, and 8) stated the food temperatures are frequently cold. Resident 6 stated I don't expect it to be hot, but it would be nice to get it at least warm. A test tray performed on the Nursing Unit on November 20, 2024, revealed the test tray arrived on the Nursing Unit at 12:15 PM. The hot meal was Swedish meatballs, mashed potatoes, mixed vegetables, and coffee. At 12:30 PM, at the time the last resident was served, the test tray was completed and yielded the following results: Swedish meatballs 115 degrees Fahrenheit, mashed potatoes were 115 degrees Fahrenheit, mixed vegetables were at 105 degrees Fahrenheit, and coffee was 107 degrees. The hot food tasted cold and was not palatable at the temperatures served. Interview with the nursing home administrator (NHA) on January 10, 2024, at 1:15 PM, confirmed that food was to be served at safe and palatable temperatures. Refer F801

Based on observation, review of facility scheduled mealtimes, select facility policy, and resident and staff interview the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including eight residents of 17 sampled (Residents 4, 25, 12, 5, 6, 18, 1, and 8). Findings include: Review of the facility's policy titled Frequency of Meal last reviewed by the facility in February 2024, indicated it is the facility's policy to provide three meals daily with not more than a fourteen (14) hour span between a substantial evening meal and breakfast unless a nourishing bedtime snack is provided. Bedtime snacks are routinely offered to all residents per preference. Review of the facility's scheduled (not exact times may fluctuate plus or minus 15 minutes) mealtimes revealed 14.25 hours between the evening meal and the next day's breakfast meal. During an interview on November 19, 2024, at 11:20 AM Resident 4 stated that staff do not provide or offer a nighttime snack. She stated that her husband brings her food, so she has something to snack on. During a group interview with seven alert and oriented residents on November 20, 2024, at 10:00 AM, all seven residents in attendance (Residents 25, 12, 5, 6, 18, 1, and 8) stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. Resident 25 reported the snacks are in a tin at the nurse's station, and staff will provide a snack if you come to the nurse's station in the evening. Resident 6 reported that he would like to receive a bedtime snack however he does not come to the nurse's station in the evening and is not offered a snack when he is in bed. Resident 18 reported she would like to receive a bedtime snack however she does not self-propel her wheelchair and is unable to bring herself to the nurse's station for a bedtime snack. During an interview on November 21, 2024, at approximately 2:15 PM the Nursing Home Administrator was unable to explain why the residents were not routinely offered and provided with a bedtime/evening snack. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on review of clinical records, the facility's admission agreement, the facility's assessment, and resident and staff interview, it was determined the facility failed to provide specialized occupational therapy and speech therapy services according to the professional standards of practice for two out of three residents reviewed for rehabilitation services (Residents 180 and 22). Findings include: Review of the facility's Admission Agreement, Section 2 Services Provided by the Facility revealed the facility agrees to provide nursing and personal care services, subacute services and physician and ancillary services. Ancillary services are physician ordered services which include pharmacy services, physical therapy, audiology services, occupational therapy, speech therapy, podiatry services, psychiatric or psychological treatment, optometric services, laboratory services, x-ray services, special nurse or companion services, oxygen therapy, dental services, and transportation services. Review of the Facility's Assessment (process used to thoroughly assess the needs of facility resident population and required resources to provide care and needed services using evidence-based, data-driven methods), last reviewed by the facility on September 30, 2024, Section 2.1 stated the types of resident care provided at the facility include the following therapies: PT (physical therapy), OT (occupational therapy), ST (speech therapy), and Respiratory Therapy. Review of the clinical record revealed that Resident 180 was admitted to the facility under Aetna Medicare PDPM (patient-driven payment model. The PDPM Medicare model was created to reduce administrative burdens for health providers by focusing on each patient's unique needs) insurance coverage on November 14, 2024, with diagnoses to include absence of the right leg below the knee (amputation), history of falling, and altered mental status. Further record review revealed the resident previously underwent a left leg below the knee amputation approximately 4 years ago. Review of Resident 180's care plan dated November 14, 2024, indicated the resident had self-care performance deficits due to impaired mobility with bilateral (both) below the knee amputations, diabetes, peripheral vascular disease, and pain. Interventions included physical and occupational therapy evaluation as ordered, provide 2 staff assistance with transfers from the bed to the wheelchair and to transfer to and from the commode using a mechanical full body lift, provide total assistance for toilet use, provide total staff assistance for bathing, provide one staff member assistance with dressing and one staff assistance for personal hygiene/oral care. Review of the physician progress note/history and physical dated November 19, 2024, revealed the assessment and plan for Resident 180 included surgical aftercare for the right below the knee amputation, wound care, supportive care by staff, fall risk, PT (physical therapy), OT (occupational therapy) and strengthening. Review of a physician order dated November 15, 2024, revealed an order for PT evaluation and treatment 3-5 times per week for therapeutic exercises, therapeutic activities, and wheelchair management training. During an interview with Resident 180 on November 19, 2024, at 10:50 AM the resident, with a BIMS score of 10 (BIMS -Brief Interview for Mental Status- a tool to assess cognitive status. A score between 8 to 12 suggests moderate cognitive impairment), reported he had not been out of bed since he arrived at the facility on November 14, 2024, five days ago and he had not left the room since he was admitted to the facility. He indicated that he had not been out of bed to attend activities, to dine in the dining room, or attend therapy in the therapy room. When asked about receiving therapy the resident replied therapy, what therapy? I barely see those people. Interview with Employee 1 (physical therapist) on November 19, 2024, at 12:40 PM verified that Resident 180 was receiving physical therapy services. However, upon further inquiry, Employee 1 revealed that Resident 180 had not received occupational therapy services since admission to the facility on [DATE], as the facility did not currently have an occupational therapist on staff. Employee 1 also revealed the facility did not currently have a speech therapist on staff. Interview with the Nursing Home Administrator (NHA) on November 19, 2024, at 2:35 PM confirmed the facility currently does not have a Director of Rehabilitation, Speech Therapist, or Occupational Therapist. The NHA revealed the last day the facility had a speech therapist was November 1, 2024, and the last day of having an occupational therapist, who was also the Director of Rehab, was November 6, 2024. Review of the clinical record revealed that Resident 22 was admitted to the facility under Medicare A insurance coverage on October 29, 2024, with diagnoses to include surgical aftercare following surgery of the digestive system, peritonitis (inflammation of the lining of the abdominal call and covering of the abdominal organs) after a ruptured abscessed appendix, mild protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and dysphagia (a condition with difficulty in swallowing liquid or food). Review of Resident 22's care plan dated October 30, 2024, indicated the resident was at risk for functional decline in ADLs (activities of daily living) related to immobility, abdominal surgery, g-tube (an endoscopic medical procedure in which a tube, gastrostomy tube, is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding/fluid when oral intake is not adequate), hypertension, weakness, history of deep vein thrombosis (blood clot), depression, and anxiety. Interventions included evaluate the resident for pain, medications as ordered, OT/PT screens as needed, out of bed to wheelchair with pressure relieving cushion with leg rests, and transfer with assistance of two staff using a mechanical lift. Review of the physician progress note/history and physical dated November 5, 2024, revealed the assessment and plan for Resident 22 included (but not limited to): 1. a very ill patient recovering from peritonitis after a ruptured abscessed appendix, nutrition is poor being supplemented by tube feeding, pain control is an issue. 2. status post C. difficile enterocolitis (bacterium that causes an infection in the colon) - no reports of continued diarrhea but malnutrition and strength are continued issues. 3. concern for skin breakdown and immobility. Wound precautions, PT/OT and good nursing care, air mattress in place. Review of a physician order dated October 29, 2024, revealed an order for PT evaluation and treatment 3-5 times per week for 30 days for therapeutic exercises therapeutic activities, neuromuscular re-education, gait training and manual therapy. Review of a physician order dated October 30, 2024, revealed an order for dysphagia evaluation, and therapy 3-5 times per week for 4 weeks to increase toleration to a mechanical soft diet. Review of a physician order dated October 30, 2024, revealed an order for OT evaluation and treatment 8-15 times in 30 days to provide therapeutic exercises, therapeutic activities, manual therapy, wheelchair management and self-care to increase safety and independence with functional tasks. Review of speech therapy documentation revealed a speech therapy evaluation was conducted on October 30, 2024, with goals established for a 4-week duration of services. The note indicated Resident 22 was provided with 15 minutes of speech therapy treatment for dysphagia therapy. At the time of the survey ending November 21, 2024, there were no additional speech therapy notes. The facility was unable to provide documented evidence that continued speech therapy services were provide to Resident 22 as prescribed. Review of occupational therapy documentation revealed an occupational therapy evaluation was conducted on October 30, 2024, with goals established for a 30-day duration of services. Continued review of occupational therapy documentation revealed one (1) daily treatment note dated October 31, 2024, indicating that Resident 22 was provided with occupational therapy treatment consisting of therapeutic activities and therapeutic exercises. At the time of the survey ending November 21, 2024, there were no additional occupational therapy notes. The facility was unable to provide documented evidence that continued occupational therapy services were provide to Resident 22 as prescribed. During an interview with the NHA on November 20, 2024, at 9:00 AM it was confirmed that facility failed to adhere to the facility's admission agreement and facility's assessment and failed to provide specialized occupational and speech therapy services to Resident 180 and Resident 22. Refer F 838 28 Pa. Code: 201.18 (a)(1)(e)(1)(4)(6) Management 28 Pa. Code: 211.12(d)(3)(5) Nursing Services

Based on the review of the facility's abuse prohibition policy and clinical records, and staff interviews, it was determined that the facility failed to report multiple instances of resident abuse perpetrated by one of nine residents sampled to the State Survey Agency (Resident M1). Findings include: A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed that regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information or such accident/incident is learned. An investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate. A PB-22 will be completed within five (5) days. A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats. During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility did not report the instances of resident abuse perpetrated by Resident M1 against other residents to the State Survey Agency. 28 Pa Code 201.14 (c) Responsibility of licensee 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights

Based on a review of clinical records and the facility's abuse prohibition policy and staff interviews, the facility failed to investigate instances of resident abuse, protect residents from the potential for further abuse during the course of an investigation and submit the results of the completed investigations to the State Survey Agency within 5 working days of the incident for multiple instances of resident abuse perpetrated by one resident out of nine sampled (Resident M1). Findings include: A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including but not limited to facility staff and other residents. Abuse includes verbal abuse, and means the willful infliction of injury, unreasonable confinement, and intimidation, resulting in physical harm, pain or mental anguish. Regardless of how minor an accident or incident may be, an investigation is implemented, and witness statements are obtained. An accident or incident form must be completed for all reported accident or incidents. The reporting and filing of accurate documents relative to incidents of abuse, reporting to state agencies as required. In Pennsylvania, include PA Department of Health/Pennsylvania Department of Aging/Area Agency on Aging as appropriate, a PB-22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) will be completed within five (5) days. A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Residen M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats. At the time of the survey ending May 16, 2024, the facility had completed investigations into the above episodes of resident abuse perpetrated by Resident M1. The resident victims were not identified in the documentation available. The facility failed to provide evidence of completed investigations, PB22's submitted to the State Survey Agency within five working days of the occurrence. During an interview on May 16, 2024, at approximately 2:05 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to investigate Resident M1's abuse of other residents and submit the completed investigations to the State Survey Agency within 5 working days of the incident. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights

Based on a review of select facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide therapeutic social services to assess the psychosocial status and needs of residents following incidents of abuse perpetrated by Resident M1. Findings include: According to regulatory guidance under S483.40(d) Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. Situations in which the facility should provide social services or obtain needed services from outside entities include, but are not limited to the following: Lack of an effective family or community support system or legal representative; Expressions or indications of distress that affect the resident ' s mental and psychosocial well-being, resulting from depression, chronic diseases (e.g., Alzheimer ' s disease and other dementia related diseases, schizophrenia, multiple sclerosis), difficulty with personal interaction and socialization skills, and resident to resident altercations; Abuse of any kind (e.g., alcohol or other drugs, physical, psychological, sexual, neglect, exploitation); Difficulty coping with change or loss (e.g., change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one); and al support. A review of the facility policy titled Abuse Protection, last revised by the facility on April 19, 2022, revealed verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms residents or their families or within their hearing distance, regardless of their age, or ability to comprehend or disability. A review of Resident M1's clinical record, revealed he was admitted to the facility on [DATE], with diagnoses to include morbid (severe) obesity due to excess calories, gastro-esophageal reflux disease (GERD), abnormalities of gait and mobility, and difficulty walking. A review of a nursing note dated December 8, 2023, at 1242 hours (12:42 PM), stating resident M1 yelling at another resident in the dayroom about how she is eating and was upsetting the other resident. The other resident stated leave me alone, however Resident M1 continued to verbally abuse the resident. A review of a behavior note, dated February 12, 2024, at 1415 hours (2:15 PM), indicated that Resident M1 was taunting a female resident, pulling his shirt up over his nose and teasing her because of her behaviors. He was making facial and hand gestures towards the female resident. Resident M1 was observed calling her A crazy bitch! Resident M1 confirmed he was mocking the other resident when staff asked. A review of a nursing note dated February 25, 2024, at 1651 hours (4:51 PM), revealed that Resident M1 was in the dayroom arguing with staff about television remote. Resident became irate cursing at staff stating, f*ck you, while throwing the middle finger stating, I pay you to take care of me and that is your job, anything that goes on in this building is my business so f*ck off. Other residents in dayroom voiced concerns about Resident M1's behavior and were kept safe at time, staff attempted to de-escalate with no effect. A nursing note dated March 18, 2024, at 1425 hours (2:25 PM), indicated that Resident M1 was verbally abusive with another resident in the dayroom. A review of a behavior note, dated March 21, 2024, at 2055 hours (8:55 PM), revealed that Resident M1 was in the dining room and loud and argumentative. The note indicated that Resident M1 Appears at times to intimidate the other residents. When asked to lower his voice a bit, he cursed. A review of a behavior note dated April 4, 2024, at 1105 hours (11:05 AM), revealed that Resident M1 was heard yelling at a resident in activities. When approaching area, he was yelling at another resident and said she's a f*cking retard. A review of a behavior note dated April 10, 2024, at 1212 hours (12:12 PM), revealed that Resident M1 was heard screaming at another resident in the dayroom. Resident continues to yell at resident causing other resident to leave area. A nursing note dated April 13, 2024, at 2236 hours (10:36 PM), indicated that there was a very loud verbal altercation in the hall and a Nursing Assistant (NA) was calling for help. Nursing noted I noticed several aides trying to restrain one of the residents who was yelling back at Resident M1 who was yelling at him. This yelling and verbal threats from Resident M1 continued and the other resident reacted in anger. Resident M1 would not go back in his room as the other resident did and continued the verbal threats. During an interview on May 16, 2024, at approximately 1:50 PM, the Director of Social Services, was unable to provide documented evidence of the facility's efforts to identify those residents affected by the above incidents of resident abuse perpetrated by Resident M1 and of the supportive social service interventions provided to assist the residents involved, directly, and indirectly (within hearing distance) following the incidents of abuse perpetrated by Resident M1. During an interview on May 16, 2024, at approximately 2:10 PM, the NHA confirmed that there was no documented evidence of social service assessment of psychosocial status and needs and provision of social service interventions provided to residents following episodes of abuse perpetrated by Resident M1. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.16 (a) Social Services

Based on review of clinical records and select resident incident/accident reports, and staff interview, it was determined that the facility failed to provide supervision and assistance with ambulation and implement planned measures to deter falls and prevent serious injury, a fractured hip, for one resident (Resident 1) out of four sampled and failed to maintain an environment free of potential accident hazards on one of one nursing units. Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and difficulty walking. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated July 21, 2023, revealed that the resident was severely cognitively impaired and required supervision with the assistance of one staff for walking in her room and on the unit. A review of the resident's care plan for potential for falls revealed planned interventions dated January 3, 2020, for a therapy screen as needed; January 3, 2020, to keep the resident's environment clutter free; August 25, 2021, for the resident to ambulate as ordered; and August 25, 2021, and revised May 15, 2023, to ensure the resident is wearing proper fitting footwear. A nursing note dated May 14, 2023, at 9:36 AM indicated that staff found the resident lying on the floor in the dining room. An incident report dated May 14, 2023, revealed that staff heard residents yelling out for help from the dining room. Staff entered the dining room and observed Resident 1 lying on the floor. The report noted that the resident was self-ambulating in the dining room, attempted to sit down, then began shaking and fell to the floor landing on her head. The facility identified the root cause of the fall was due to the resident's shoes being too big. There was no evidence of staff supervision in the dining room or that Resident 1 was being supervised or assisted with ambulation at the time of the fall. A nursing note dated May 14, 2023, at 4:26 PM indicated the facility planned to initiate 15 minute checks of Resident 1. Facility documentation revealed that staff conducted every 15 minute checks of the resident until 11:15 PM on May 14, 2023 (approximately 7 hours after the resident had fallen that afternoon). There was no documented evidence that the facility had continued to provide increased supervision of the resident's activities to promote resident safety and prevent additional falls. A progress note dated June 7, 2023, at 8:31 PM revealed that staff heard the resident calling out from another resident's room. Staff found the resident on the floor complaining of left foot pain. The resident stated at that time she had tripped on a floor mat next to the bed in that room. An incident report dated June 7, 2023, revealed that the resident was found on the floor in another resident's room. The facility identified the root cause of the fall to be the resident self-ambulating into another resident's room. According to this report the resident would be provided increased supervision and a therapy screen would be conducted. A review of the resident's clinical record conducted during the survey ending October 26, 2023, revealed no documented evidence that a therapy screen was conducted after the resident's fall on June 7, 2023. There was also no evidence that the facility staff had increased supervision of the resident. A review of the resident's care plan for potential for falls revealed no new planned interventions after the resident's fall on June 7, 2023, to prevent further falls. A nursing note dated October 14, 2023, at 9:48 PM revealed that Resident 1 was standing at the nursing station. The resident then stumbled over her feet falling to the ground landing on her bottom and her back. An incident report dated October 14, 2023, indicated the resident had fallen while standing at the nurse's station. The resident tripped over her feet and landed on the ground. The facility identified the resident wasn't wearing shoes but was wearing non-skid socks. A PT (physical therapy) screen was recommended at that time. A review of the resident's clinical record revealed no evidence that the physical therapy screen was completed after the resident's fall on October 14, 2023. A review of the resident's care plan for potential for falls revealed no new planned interventions after the resident's fall on October 14, 2023, to prevent further falls. A review of an occupational therapy (OT) encounter note dated October 17, 2023, revealed that the resident had ambulated with OT to the dining room with hand held assistance and fair balance. An OT encounter note dated October 18, 2023, indicated that the therapist conducted functional mobility with the resident with new shoes on. At that time, the resident displayed increased tripping and shuffling with the left foot. The resident was using the therapist and furniture for stabilization. The resident's shoes were removed and they were not recommended for the resident's use at that time. A review of an OT encounter note dated October 19, 2023, revealed that functional mobility was completed with the resident. The resident ambulated around with facility with the occupational therapist. It was noted that the resident continued to shuffle when she walks and showed varied understanding with provided education. A nursing note dated October 20, 2023, at 7:56 AM revealed that at 7:29 AM on that date staff witnessed the resident fall. An incident report dated October 20, 2023, indicated that staff heard calls for help and found the resident in the hall on the floor. Employee 1, housekeeping staff, reported at that time that the resident was walking down the hall and then fell to the floor. The resident reported pain in her left leg after the fall. The facility indicated that the resident was to be screened by PT (physical therapy) and wear proper footwear. Occupational therapy noted on October 18, 2023, that the resident's shoes were not recommended for the resident's use. There was no evidence of the appropriateness of the resident's footwear at the time of the resident's fall on October 20, 2023. A review of an x-ray report dated October 20, 2023, revealed the resident had sustained a left intertrochanteric fracture with varus angulation (hip fracture) as a result of this fall. The resident was transferred to the hospital on October 20, 2023, and returned to the facility on [DATE]. A review of the resident's clinical record conducted during the survey ending October 26, 2023, revealed a PT screen was not completed after the resident's fall on October 20, 2023. A review of the resident's care plan for potential for falls indicated that on October 20, 2023, the facility implemented a new intervention for the bed to be in the lowest position despite the resident not falling from her bed but while ambulating on the unit. An interview with the Employee 2, Director of Rehab, on October 26, 2023, at approximately 9:30 AM confirmed that there was no documented evidence that PT (physical therapy) had ever screened the resident after the above noted falls in the facility. She further confirmed that there are no notes from physical therapy to indicate that the resident was ever seen or treated by PT since her admission to the facility on [DATE]. She stated PT would be the discipline responsible for assessing the resident's ambulation and determine the resident's needs for appropriate assistance with ambulation for her for safety. The facility repeatedly identified the planned approach of physical therapy screening of the resident after falls, which were not conducted. There was no evidence of a thorough and accurate assessment of the resident's functional ambulation abilities and level of assistance needed or any assistance devices that may be required. The facility failed to implement planned interventions, including physical therapy screens and assuring appropriate footwear, to prevent falls while ambulating, and failed to provide necessary staff supervision and assistance with ambulation to prevent falls and serious injury to the resident. Observation on the facility's one resident unit on October 26, 2023, at 9:47 AM revealed the hallways of the resident unit were lined with linen carts, housekeeping carts, wheelchairs, broad chairs, and mechanical lifts, obstructing access to the handrails. Observation on the nursing unit on October 26, 2023, at 1:15 PM revealed the handrails remained obstructed with linen carts, housekeeping carts, wheelchairs, broad chairs, and mechanical lifts. Interview with the director of nursing and nursing home administrator on October 26, 2023, at approximately 1:45 PM confirmed the facility failed to provide individualized effective safety interventions and necessary staff assistance and supervision to Resident 1 to prevent falls. The NHA and DON also confirmed that the halls of the resident unit were lined with equipment, preventing unimpeded access to the handrails and creating an impediment to resident mobility. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 201.18 (e)(2.1) Management

Based on a review of clinical records and select incident reports and staff interview, it was determined that the facility failed to provide effective individualized fall prevention measures to address a resident's known risk factors for falls to prevent an avoidable fall and serious injury, a neck fracture, for one out of 8 sampled residents (Resident CR 1). Findings include: A review of Resident CR 1's clinical record revealed that the resident was readmitted to the facility May 31, 2019, with diagnoses to include muscle weakness, lack of coordination, [CONDITION(S)] (chronic [CONDITION(S)] lung disease that causes obstructed airflow), and abnormalities of gait and mobility. An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 30, 2021, revealed that Resident CR 1 was severely cognitively impaired, and required extensive assistance with bed mobility, transfer, toilet use, personal hygiene and dressing. A review of the resident's care plan (information used for staff reference when providing a resident's direct care) initially dated September 7, 2016, revealed that the resident needs extensive assistance with activities of daily living (ADL's), including assistance with changing positions in bed. The plan of care for the resident's risk for fall dated September 6, 2016, revealed the planned intervention of keeping the resident's bed in the lowest position and call bell in reach. There were no other interventions planned relating to preventing falls from bed identified on the resident's plan of care. The resident's care plan, dated March 16, 2018, revealed that the resident required the use of a mechanical lift with assistance of two staff for transfers A continued review of the clinical record revealed a facility fall assessment (documentation tool used to predict falls) dated April 24, 2021, revealing that Resident CR 1 scored a 12, which indicated that the resident was at high risk for falls. A review of a facility incident report revealed that Resident CR 1 sustained a fall on May 28, 2021, at 9:20 PM. The report indicated that the resident was heard calling out and upon staff entering the resident's room, found her lying face down on the floor next to the window side of the bed. A skin tear was noted to the left posterior hand and small bruise formed to left side of head. Nursing progress notes dated May 28, 2021, revealed that the resident was found on the floor. The resident stated that she did not know how she fell , stating I just rolled out. The resident's physician and family were called and the resident was transferred to the hospital emergency room for evaluation and treatment on May 28, 2021. The facility's incident report dated May 28, 2021 revealed that Employee 1, Certified Nursing Assistant (CNA), had observed Resident CR 1 snug in bed approximately 1 hour and 20 minutes prior to the fall. In the notes section, dated May 30, 2021, a follow up interview the facility conducted with Employee 1 on May 29, 2021, was noted. Employee 1 stated she (Resident CR1) leans to the side sometimes. Fall mats were placed at the side of the resident's bed as an immediate intervention. The incident report also noted that plan following the resident's fall from bed on May 28, 2021, was an OT evaluation and the placement of a perimeter mattress (creates a raised rail, defined perimeter for enhanced fall prevention, without using patient restraints. Open in mid-section for safe and easy patient egress and ingress. Built-in medium density foam bolsters safely and comfortably define edges of bed for patient and prevent falling) as a preventative measure to prevent further falls from bed. Nursing progress note dated May 29, 2021, indicated that Resident CR 1 was admitted to the hospital with a dens fracture (A fracture of the odontoid bone {also called the dens}, is an upward extension of C2 cervical vertebrae (i.e., axis) up into the C1 cervical vertebrae (i.e., atlas, a tooth like projection of bone on the second cervical vertebra). A review of hospital progress note - neurosurgery dated May 29, 2021, at 8:50 AM, revealed that Resident CR 1 had sustained a type II dens (odontoid - a tooth like projection of bone on the second cervical vertebra) fracture, questionable nondisplaced right C 1 (first cervical vertebra) foramen transversarium fracture, and possible left distal clavicle fracture. Interview on June 15, 2021, at approximately 11:30 AM, with Employee 2 (Physical Therapy Assistant), confirmed that Resident CR1 was known to lean to the side, while both in a chair and bed. Employee 2 stated that based on the resident's limited bed mobility (the resident required extensive assistance with bed mobility) it was highly unlikely that Resident CR 1 could roll out of bed unassisted. Facility staff, both Employee 1, CNA and Employee 2, PTA were aware of the resident's habit of leaning to the side while in bed, but the facility failed to timely address this risk factor for falls and injury. It was not until after the resident's fall from bed and neck fracture that the facility initiated measures to prevent falls from bed and risk for injury (the placement of fall mats and a perimeter mattress) The facility failed to timely implement effective preventative measures to maintain the resident's resident's safety by failing to promptly address the resident's known unsafe behaviors and prevent an avoidable fall resulting in a neck fracture on May 28, 2021. During an interview on June 15, 2021, at approximately 2:00 PM, with the Nursing Home Administrator (NHA) failed to provide evidence that effective safety and fall prevention interventions were provided to this resident, with known fall risk factors, to prevent the fall resulting in a neck fracture. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services Previously cited 2/6/20, 12/4/20, 4/22/21, 6/15/21 28 Pa. Code 211.12(c) Nursing services Previously cited 2/6/20, 10/29/20, 12/4/20, 4/22/21, 6/15/21

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide adequate supervision/assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls and injury for one of 10 sampled residents (Resident 24). Findings include: A review of the clinical record revealed that Resident 24 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated April 26, 2013, revealed that the resident was cognitively impaired, required staff assistance for activities of daily living, including the assistance of one staff for transfers and ambulation. The MDS assessment also indicated in the area of balance during walking and turning around the resident was coded as not steady and only able to stabilize with staff assistance. Review of the resident's revised care plan dated May 30, 2013, revealed that three of the problematic areas included were decline in intellectual functioning, potential injury due to exit-seeking behaviors and falls, related to impulsivity, poor safety awareness, disorganized thinking and psychomotor retardation. Care planned interventions at the time and up until June 2013, included one-on-one as needed, a bed sensory alarm, a velcro alarm belt in wheel chair, a low bed, visual cues, remind resident use call bell and the assist of one staff member with transfers and roller walker (an assistive device used to aid in walking). A review of a "Nursing Admission Assessment" in the areas of Elopement and Fall Risk dated January 24, 2013 and April 19, 2013, revealed that Resident 24 was disoriented to person, place and time, had an unsteady gait, is unable to ambulate independently, lacks awareness to use handrails or arm rests, cannot transfer safety without assistance or supervision. A review of a Physical Therapy Progress and Discharge Summary dated May 6, 2013, revealed that the resident needed maximum cues to participate and complete each physical therapy (PT) session. The resident's decreased cognition affected overall progress throughout the course of care. The summary identified that the resident continued to need increased visual, verbal and tactile cues to increase safety, consistency and ability with all transfers and ambulation. The summary of skilled PT services provided at that time revealed that the resident was able to ambulate with the hand held assistance of one staff member; however, it also revealed that the resident's varying level of cognition affected her overall safety, balance, ambulation and transfers. A review of the nursing documentation from April 1, 2013, at 2:55 p.m. through May 28, at 11:03 p.m., indicated similarly documented behavior that included the following: "unclipping her safety belt numerous times, taking seat belt off and saying I'm going home, redirected and encouraged with no effect, yelling loudly, refusing to use safety devices, ambulating fast up and down hall way, transfers are unsteady and needing safety reminders, occasionally refuses to use roller walker, resident verbally and physically aggressive toward staff, getting up by herself and not using call bells, attempted to walk on her own, attempted to go out door, slapping staff 1 to 1 provided with no effect, displaying numerous episodes of exit-seeking behaviors, refusing to seat in wheel chair or bed, standing in hall trying to open exit door 1 to 1 one ineffective, standing up by exit door prn (as needed) gel Ativan (an anti-anxiety medication) given, uncooperative with therapy, fixated on going home, unable to redirect, will shut off alarms and self transfer, requires frequent cueing at times, resident with 1 to 1 staff for increase behaviors." Examples of these types of behavior were by noted by nursing staff on 75 occasions and documented in the resident's clinical record. A review of a nurses' note dated May 5, 2013, at 10:50 a.m., and a corresponding "Incident/Accident Report" revealed that the LPN awoke the resident at 5:45 a.m. to give her medicine when the resident started yelling and attempted to sit up and transfer out of bed. The resident was given prn Ativan gel, put on her sneakers and sat at the bedside. The bed alarm was on. At 6:15 a.m. the resident's alarm was sounding and resident was observed on the floor. A review of a nurses' note dated May 20, 2013, at 8:40 a.m., and a corresponding "Incident/Accident Report" revealed that the bed alarm sounded and the resident was found on the floor by the bed. The resident attempted to self transfer. The facility added a new intervention of a scoop mattress at that time. A review of a nurses' note dated May 22, 2013, at 8:40 a.m., and a corresponding "Incident/Accident Report" revealed that the resident was walking with the walker and the nurse aide (NA) was following her with a wheelchair. When the NA pulled the wheel chair up under the resident, the resident pushed away the walker and tried to turn around and fell to the her right side. Later at 10:00 p.m., the resident complained of right hip pain. The Physican was notified and orders were received for an x-ray of the right hip. Review of an x ray dated May 22, 2013, revealed that the resident had non-displaced fractures of the left pubic rami. New intervention added at that time was to ambulate with roll walker and assist of two with wheelchair to follow. A review of a nurses' note dated May 25, 2013, at 11:30 a.m., and a corresponding "Incident/Accident Report" revealed that the resident was refusing care from the nurse aide. The resident was sitting in her wheel chair at the emergency door attempting to self transfer removing her seat belt with the alarm sounding. As nurse was walking toward the resident, the resident stood up and fell down. Interventions added at that time included a psychiatry follow-up and to continue to follow the resident's care plan. A review of a nurses' note dated May 28, 2013, at 11:00 p.m., and a corresponding "Incident/Accident Report" revealed that the resident was found sitting on the floor next to the bed with the bed alarm sounding. New interventions added at the time included weight-bearing as tolerated and a low bed. A review of the nursing documentation prior to the falls of May 5, 20, 22 and 25, 2013, revealed that Resident 24 exhibited unsafe behaviors before each fall. On May 5, at 5:45 a.m., the nurse documented that the resident had attempted transfer out of bed, refused care and was yelling at staff. At 6:15 a.m. a nurse noted that the resident had fallen out of bed. On May 20, at 5:25 p.m., a nurse noted that the resident was banging her shoe against the door, yelling out with 1 to 1 provided and efforts ineffective. Later at 6:50 p.m., a nurse documented that the resident continues to yell, 1 to 1 provided, returned to her room and efforts remained ineffective. At 8:40 p.m., a nurse noted that the resident had fallen out of bed. On May 22, at 10:15 a.m., a nurse documented that the resident took her shoe off and started to hit the door demanding to go home, prn Ativan gel given which was effective; however, five hours later, the resident showed signs and symptoms of anxiety and prn Ativan gel was given. At 4:06 p.m., a nurse noted that the resident fell while walking with an NA which resulted in a fracture. On May 25, at 10:49 a.m. and at 11:11 a.m., a nurse indicated that the resident attempted to self transfer several times out of bed in the morning and attempted to stand up on her own with redirection unsuccessful. Later at 11:30 a.m., a nurse documented that the resident was at the emergency door, screaming and trying to hit the NA and as the LPN was walking down the hallway removed the velcro seat belt again, stood up from the wheel chair and attempted to walk without assistance and fell to the ground. Further review and comparison of the PT Discharge Summary dated May 6, 2013, and the care plans in effect during her unsafe behaviors and falls from May 2013 and the Accident/Incident report dated May 22, 2013, revealed that the resident was care planned to ambulate with a roller walker and the assist of one, while the physical therapist indicated that the resident could ambulate with hand held assist of one staff with minimum assist. Conversely, the Accident/Incident report indicated that when the resident fell and suffered a non-displaced fracture, she was ambulating with a roller walker and the staff member was pulling a wheel chair behind the resident. These documented differences in the resident's ambulation status at the time of her fall revealed that the facility failed to identify, through its investigation, the resident's appropriate ambulation status based on her behavioral symptoms and functional abilities. In addition, the facility was unable to provide documented evidence of the 1 to 1 provided during the period from April 2013 through May 2013, when Resident 24 was exhibiting the unsafe behaviors. There was no evidence that the facility had evaluated the resident for the type and degree of staff supervision required to prevent repeated unsafe behaviors, falls and the potential for injury. The facility instituted approaches following each fall, but the facility failed to provide increased staff supervision of the resident during the resident's at risk periods, either while the resident was in bed and/or, out on the unit. Interview with the nursing home administrator and the director of nursing on January 8, at approximately 10:25 a.m., failed to provide evidence that the resident, who had a history of [REDACTED]. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 2/13/13