Every finding on record at Landis Homes

Based on staff interviews, clinical record and facility documentation review it was determined the facility failed to ensure that one of 19 residents reviewed was free from accidents by failing to provide adequate supervision resulting in harm to Resident 11 who sustained a scalp laceration. Findings include: Review of Resident 11's diagnosis sheet revealed diagnoses Alzheimer's Disease (memory loss, cognitive decline, behavior changes), Vascular Dementia Severe with Mood Disturbances, Vascular Dementia Severe with Agitation, Vascular Dementia Severe with Psychotic Disturbance (group of conditions that cause a decline in cognitive function, including memory, thinking, reasoning, and problem solving, severe enough to interfere with daily life), and Lack of Coordination.Review of Resident 11's Care Plan revealed a care focus titled Hygiene Assistance with Activities of Daily Living (ADLs) indicating the resident has an ADL self-care performance deficit with bathing, dressing, and feeding related to vascular dementia and history of fractures requiring 2-person assistance with transfers, bed mobility, toileting, and bathing, initiated May 5, 2025.Review of Resident 11's Care Plan revealed a care focus titled the Resident is combative and resistive to care related to Dementia. Review of Resident 11's Quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated September 15, 2025, revealed Resident 11 was dependent on staff for transfers, showering or bathing.Review of Resident 11's Quarterly MDS dated [DATE], revealed the resident has a BIMS (brief interview for mental status) score of 0 indicating severe cognitive functioning.Review of Resident 11's progress notes revealed a nursing note dated September 13, 2025, at 7:38 a.m., indicating Resident 11 was sent out to hospital, 2 assisted to shower room this morning. Once shower started, resident increased behaviors, yelling and threw self out of shower chair. Hit head against wall. Seen laying on right side. 3 assisted up to wheelchair. Large laceration noted to top right head, measures 12x6 cm (centimeters) with flap of skin, unable to approximate. Pressure applied to stop bleeding with ice. Resident did not lose consciousness. Continue with combativeness and aggression. Bleeding noted to stop. Sent to ED (Hospital Emergency Department) at 7:30 a.m. POA (Power of Attorney-person legally authorized to make decisions on behalf of another person) updated per supervisor.Review of Resident 11's hospital discharge report, dated September 13, 2025, revealed a right scalp laceration requiring 26 staples.Review of information dated September 13, 2025 submitted to the state agency revealed Resident 11 fell out of a shower chair on Saturday, September 13, 2025, at 0730 (a.m.) and sustained a laceration with a flap to his/her scalp measuring 12 cm x 6 cm. Resident POA (Power of Attorney) and On-call MD (Medical Director) notified and sent to a Community Hospital for evaluation and sutures. Investigation initiated.Further review of information submitted to the Department on September 13, 2025, revealed under subheading titled Follow-up: staff statements obtained; and according to staff statements they transferred resident with 2-person assist to the shower chair and then took the resident to the spa room where Certified Nurse Aide Employee E4 proceeded to provide the resident with a shower. The resident was combative trying to hit and bite the employee, the employee handed the resident a washcloth in attempts to distract his/her attention, the resident lunged at the employee, causing the resident to fall out of the shower chair. Staff did not follow care plan to have 2 staff present for shower. Staff suspended pending further investigation, [NAME] County Office of Aging Notified. Education to entire team will be provided to follow plan of care, and to stop care if resident is agitated. The resident returned from the hospital with following report: CT (computed tomography) head and cervical spine negative for acute injury. No bleed. Tetanus immunization updated. Laceration repaired. Patient is stable for discharge and outpatient follow-up. Head injury precautions given. PB22 to follow. Resident's BIMs 00/15 Resident will be bed bath with 2-person assist. September 16,2025, PB22s submitted.Review of facility investigation into the injury revealed a witness statement from certified nurse aide Employee E3, dated September 13, 2025, indicating Employee E3 and certified nurse aide Employee E4 both wheeled the resident into the shower room. Employee E3 then told Employee E4 to use the call bell if assistance was required then left the shower room. The call bell rang approximately two minutes later, when Employee E3 returned to the shower room the resident was noted as on the floor bleeding. Employee E5 was called in to assist with getting the resident back into the wheelchair.Review of facility investigation into the injury revealed a witness statement from Employee E4 indicating Employee E4 attempted to shower the resident alone, the resident was trying to bite and grab Employee E4. Employee E4 handed the resident a washcloth so the resident could assist with washing and divert the resident's attention. The resident lunged at Employee E4 causing the resident to fall out of the chair. The emergency button was activated, and additional staff came to assist with getting the resident back into the chair.Review of facility documentation of the investigation into incident revealed a witness statement from licensed nurse Employee E5 indicating Employee E5 was alerted to come into the shower room, observed the resident laying on the floor, blood was noted with shower water running, resident continued with combativeness and agitation. Pressure was applied to the resident's head wound and resident was assisted by 3-persons back into the wheelchair. Resident did not lose consciousness. Resident was sent to emergency room and POA was notified.Phone interview with the Nursing Home Administrator on September 29, 2025, at 10:47 a.m. confirmed Resident 11 was not appropriately supervised during care, resulting in actual harm when Resident 11 sustained a scalp laceration requiring transfer to the emergency department for suture repair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based upon review of facility policy and procedure, observation, review of clinical records and interview, it was determined the facility failed to ensure proper infection control procedures during a COVID-19 outbreak on one of four units reviewed (Ephrata House). Findings include: Review of facility policy and procedure titled Interim COVID-19 Visitation Policy, dated October 19, 2022, revealed The core principles of COVID-19 infection, prevention will be adhered to and as follows: Visitors who are unable to adhere to these principles of COVID-10 infection prevention will not be permitted to visit or will be asked to leave. Further review of this policy revealed Visitors will be allowed during outbreak investigations, but visitors will be made aware of the potential risk of visiting during the outbreak investigation and adhere to the core principles of infection prevention. If visiting, during this time, residents and their visitors should wear face coverings or masks during the visits, regardless of vaccination status, and visits should ideally occur in the resident's room. Further review of this policy revealed While an outbreak investigation is occurring, the facility should limit visitor movement in the facility and visitors should go directly to the resident's room or designated visitation area and physically distance themselves from other residents and staff, when possible. Visitors will be notified about the potential for COVID-19 exposure in the facility and adhere to the core principles of COVID-19 infection and prevention, including effective hand hygiene and use of face coverings. Interview with the Nursing Home Administrator on November 28, 2022, at 9:15 a.m. revealed five residents in Ephrata House were diagnosed as having COVID-19 and the facility was experiencing an outbreak of COVID-19. This interview further revealed PPE requirement for staff and visitors within the facility, including Ephrata House, was surgical masks and goggles/face shields. Observation of Ephrata House personnel on November 28, 2022, at approximately 10:00 a.m. revealed staff members wearing surgical masks and face shields/goggles. Review of Resident 7's clinical progress notes dated November 24, 2022, revealed Resident received visitors this AM. Grandson was among visitors. Caregiver notified that grandson was refusing to wear a mask while in facility. Writer approached grandson and educated at length on reasons why masks are strongly encouraged while in a healthcare facility. Grandson continued to refuse wearing a mask. Visitors currently in resident's room. Supervisor notified. Interview with Licensed Employee E2 on November 29, 2022, at 10:00 a.m. failed to reveal any evidence as to whether the visitor signed in at the kiosk, failed to reveal evidence of any personnel in the reception area, failed to reveal evidence regarding the length of time the visitor was in the facility, failed to reveal evidence of the location of the visitor while in the facility and failed to provide an outcome to the visitor situation that occurred on November 24, 2022. Interview with Licensed Employee E2 on November 30, 2022, at 10:00 a.m. revealed that an additional resident in Ephrata House tested positive for COVID-19 in the evening on November 29, 2022, five days after the November 24, 2022, visitor incident. The interview further revealed that the resident's husband had been notified but no contact tracing had been completed at the time, as the resident had only been diagnosed the previous evening. Review of documentation submitted to State agency regarding the November 29, 2022, positive resident revealed all staff were dedicated to COVID-19 specific residents and all staff were wearing N95 face masks and face shields/goggles. Interview with Licensed Employee E3 on December 1, 2022, at 9:40 a.m. revealed that Licensed Employee E3 had been administering medications to all residents on Ephrata House unit without regard to COVID-19 status. The interview further revealed that dedicated nurse aides were assigned to the COVID-19 positive residents, however, nursing staff was not dedicated. Observation of the Ephrata House staff on December 1, 2022, at 10:00 a.m. revealed staff to be wearing N95 face masks and face shields/goggles. Interview with Nursing Home Administrator on December 1, 2022, at 11:00 a.m. revealed the Ephrata House staff were wearing face shields/goggles and N95 masks at all times and that the survey team was informed about the N95 masks upon entrance. The survey team was informed, upon entrance, that PPE requirements in the entire building were surgical masks and goggles. The interview further revealed that after the supervisor was notified of the visitor on November 24, 2022, the supervisor arrived on the unit to find that the visitor had left the immediate unit. The interview failed to reveal where the visitor went within the facility and no monitoring of this visitor occurred during the visit. No further information was available or provided regarding this incident. The facility failed to follow COVID-19 policies and procedures and failed to adequately ensure the safety of additional residents from COVID-19 infection during an outbreak at the facility. 28 Pa Code 211.10(a)(d) Resident Care policies 28 Pa Code 211.12(a)(c)(d)(4)(5) Nursing Services

Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure residents were free from a significant medication error for one of 18 residents reviewed (Resident 31). Findings include: Review of Resident 31's diagnosis list revealed Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident 31's physician's order dated November 16, 2022, revealed Novolog (fast-acting insulin) nine units with breakfast and dinner and three units with lunch. Hold if the resident does not eat or if blood sugar is below 90. Notify MD for blood sugar below 60 or above 400. Additional review of Resident 31's clinical record revealed a physician's order dated November 17, 2022, revealed When supply is complete, D/C (discontinue) Novolog and start Humalog (fast-acting insulin). Further review of the same form revealed the order was faxed to the pharmacy on November 18, 2022, at 6:00 p.m. The Novolog order was discontinued, and the Humalog order was placed as a draft (order). Review of nursing progress notes dated November 21, 2022, (3:21 a.m.), revealed upon chart checking, the nurse discovered the pharmacy discontinued the Novolog order with the new order (insulin) not being active. The same note revealed that due to this incident, Resident 31 did not receive insulin before meals on November 19, and 20, 2022, missing a total of 6 insulin doses (four doses of Novolog -nine units and two doses of Novolog- three units). Interview conducted with the Director of Nursing (DON) on November 30, 2022, at 1:00 p.m. revealed that due to the resident's insurance, Humalog was substituted for the Novolog order. The DON reported that the resident still had a supply of Novolog insulin in the facility, physician was notified and made an order to discontinue Novolog when completed and then start Humalog. The DON reported per the facility's investigation, licensed Employee E7 faxed the written order to the pharmacy with the intent to update the pharmacy as to when the Novolog insulin will be completed. The DON confirmed no staff member followed up with the pharmacy to indicate the date when the Novolog insulin will be completed and discontinued. The DON reported that the pharmacy discontinued the Novolog insulin and placed the Humalog insulin order into a draft (order) which should have been activated by the nurse on duty. The DON confirmed the nurse did not activate the order resulting in Resident 31 with no active insulin order for November 19, and 20, 2022. The facility failed to ensure Resident 31 was free from a significant medication error. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(5) Nursing Services

Based on observation, review of facility documentation and staff interviews it was determined, the facility failed to maintain the safe operating condition of four dryers in the laundry department. Findings include: On January 24, 2020, at 10:14 a.m., a tour of the laundry department was conducted with the Campus Services Administrator, Employee E3, and the Laundry Supervisor, Employee E4. The laundry tour revealed dryers two and four with heavy lint accumulation on the screen lint trap, and moderate lint accumulation on the basket lint trap for dryers one and three. An interview with Employee E4 on January 24, 2020, at 10:23 a.m., revealed that all four dryers were last cleaned on January 23, 2020, at night time. Employee E4 further stated that they do not have a log/documentation of checking and cleaning the lint compartment of the dryers. An interview with Employee E3 on January 24, 2020, at 10:23 a.m., revealed that the facility does not have a policy and procedure for checking and cleaning the dryers for lint accumulation. Employee E3 further stated that they follow the manufacturer's guidelines in cleaning the dryers. A review of the facility documentation titled Dryer Lint Compartments, undated, revealed: 1. Dryer one-clean out at the end of every day. 2. Dryer two-every three loads (dryer will automatically remind you when it is time to clean out). 3. Dryer three- cleanout at the end of every day. 4. Dryer four- check after every load and clean as needed. A review of the facility documentation, Dryer Cleaning Log revealed that the dryer lint drawers are checked/cleaned after every load, the dryer cleaning log is only to record the times the drawers are taken out and the lint is cleaned out of the basket ' s corners and behind the drawers, which is done every other week. The log was last signed on January 10, 2020. The facility failed to maintain safe operating conditions of the four dryers in the laundry department. Essential Equipment, Safe Operating Condition CFR(s): 4[AGE].9(d)(2) 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code: 207.2(a) Administrator's responsibility 28 Pa. Code: 205.26(c) Laundry

Based on the facility policy, resident interview, observation and staff interview, it was revealed that the facility failed to ensure that patient care equipment was set up in a safe operating condition for one of 20 residents reviewed (Resident #75). Findings include: Review of the facility policy titled Air Mattress revealed that they are placed on top of the regular mattress, connect tubing to mattress and pump, making sure tubes are connected tightly and have no kinks, plug into electrical outlet. Air should fill alternate tubes, If not filling with air, check for holes. An interview with Resident #75 on (MONTH) 8, 2019 at approximately 9:00 a.m. revealed that the resident did not sleep well due to his mattress being over filled. Further interview revealed that the facility staff put the new air mattress on last evening and the setting was much harder during the night. Resident #75 stated that the nurse turned the knob down this morning, but it still did not feel right. Surveyor looked at the dial on the pump and it was at 7 o'clock. Resident #75 stated that the bed did not feel like it was working right. Observation of the air mattress and pump revealed alternating pressure mattress stated on the pump. Further observation of the mattress revealed the mattress being very stiff and not filling the tubes with alternating turns. An interview with Licensed nursing Employee E6 on (MONTH) 8, 2019 at approximately 9:15 a.m. revealed that she did not believe that the mattress was functioning properly. Licensed nursing staff, Employee E6 could not tell me how the proper settings were found for Resident #75 and did not know who to call to find this information out. An interview was conducted with Nursing home Administrator on (MONTH) 11, 2019 at approximately 2:18 p.m. revealed that the facility owns alternating pressure mattresses and did not know who was responsible to make sure that it was functioning properly. The facility failed to ensure that the patient care equipment was set up in a safe operating condition for Resident #75. 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on clinical record review and staff interview, it was determined that the facility failed to document the rationale for continuing an order for [REDACTED]. Findings include: Review of Resident #72's (MONTH) 2019 physician's orders [REDACTED]. Interview with Licensed nursing staff, Employee E5 on (MONTH) 12, 2019 at 11:15 a.m. confirmed that the physician failed to re-evaluate the need for the as needed anti-anxiety medication when the intended duration of order expired for resident #72. The facility failed to document the rationale for continuing an order for [REDACTED]. 28 PA Code 211.5(f) Clinical records Previously cited [DATE] 28 PA Code 211.10(a) Resident care policies 28 PA Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of five residents reviewed (Resident# 72). Findings include: Review of Resident #72's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident #72's physician orders [REDACTED]. Review of Resident #72's (MONTH) 2019 Medication Administration Record [REDACTED]. There was no further documentation to justify why both medications were administered simultaneously. Further review of Resident #72's (MONTH) 2019 MAR indicated [REDACTED]. There was no further documentation to justify why both medications were administered simultaneously. An interview was conducted with the Nursing Home Administrator on March12, 2019 at approximately 11:45 a.m. revealed that it would be her expectation that the nursing staff would wait thirty minutes to an hour to see if one of the medications worked before administering the second medicaiton. 28 Pa. Code 211.5(f) Clinical Records Previously cited 1/31/18 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of nursing assistant competencies and inservice training, it was determined that the facility failed to ensure that all nursing assistants completed annual in-service education regarding abuse and neglect for one of five employees reviewed (Employee #E4). Findings include: Review of five certified nursing assistant annual competencies revealed that Employee #E4 had not completed annual in-service training regarding abuse and neglect by (MONTH) 1, (YEAR). Further review revealed that Employee #E4 works in the facility as a Life Enrichment aide and is cross trained as a nursing assistant. Between the dates of (MONTH) 1, (YEAR) and (MONTH) 1, (YEAR), Employee #E4 did not complete annual in-service training regarding abuse and neglect or complete 12 hours of mandatory annual training to maintain nursing assistant certification. Interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 12, 2019 at approximately 1:20 p.m. confirmed that Employee E#4 did not have the proper amount of hours or annual in-service training regarding abuse and neglect to maintain nursing assistant certification. 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited: 1/31/2018

Based on observation, facility policy, resident and staff interviews, it was determined that the facility failed to ensure dignity for 3 residents (Resident 9, Resident 13, Resident 17) on one out of 4 units observed. (Ephrata House) Findings include: Observations conducted on (MONTH) 29, (YEAR) at approximately 12:30 p.m. on the Ephrata House of Resident 9 revealed that Resident 9 was in electric scooter eating lunch with a gait belt around upper stomach area just below breast (gait belt placed around resident's waist to aid the nursing staff in transferring resident from one surface to another). Resident 9 was observed propelling towards her room from dining area after the completion of the meal. Interview conducted with Resident 9 in her room following the observation revealed that the staff forgets to take her gait belt off after transferring her into the scooter and it happenes often. Observation of Resident 9 on (MONTH) 29, (YEAR) at 1:20 p.m. still with the gait belt on as they were heading to a group meeting off unit. Continued observation of Resident 9 on (MONTH) 29, (YEAR) at approximately 2:26p.m, revealed that Resident 9 still had the gait belt on. During the resident group meeting on (MONTH) 29, (YEAR) at approximately 1:30 p.m Resident 9 made a statement that the nursing staff was lazy. When the surveyor asked for clarification Resident 9 tugged at the gait belt that remained around the resident's waist and stated this was not very comfortable to wear all day. Observation on (MONTH) 29, (YEAR) at approximately 12:20 p.m. of Resident 13 revealed that the resident was sitting in a wheelchair in the common area of Ephrata House with a gait belt around his waist. Resident 13 continued to sit in the common area wearing a gait belt until approximately 1:20p.m. when brought to his room for toileting. Observation on (MONTH) 30, (YEAR) at approximately 1:15 p.m. on the Ephrata House, revealed that Resident 17 was observed sitting in recliner in his room with a gait belt around his waist. Continued observation of Resident 17 at 1:45p.m. revealed that the nursing assistant entered room at 1:45p.m. and toileted resident and removed the gait belt. Interview on (MONTH) 31, (YEAR) at approximately 9:30 a.m with Nursing Home Administrator and Director of Nursing revealed that the expectation is that the gait belt be removed once transfer of resident was completed. The facility failed to ensure dignity of three residents involving removal of gait belt once the transfer from one surface to another was completed. 28 Pa Code 211.11 Resident care plan 28 Pa Code 211.12 (c)(1)(3)(5) Nursing services

Based on observation, review of clinical records, review of facility policy and procedure, and resident and staff interview, it was determined that the facility failed to ensure that medications were not left unattended for one of 19 residents reviewed (Resident R27). Findings include: Review of policy and procedure entitled Medication Administration General Guidelines, revised (MONTH) 14, 2014, revealed Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Remain with the resident until all medications have been administered unless self-administered. Do not leave any medications at the resident's bedside. Review of the Resident 27's Quarterly MDS (Minimum Data Set-an assessment completed regularly to identify resident care needs) dated (MONTH) 24, (YEAR) revealed that the resident's BIMS (Brief Interview for Mental Status) was coded at a 5 indicating severe impairment cognitive ability (thinking and decision making ability). Further review of the quaterly MDS assessment [DIAGNOSES REDACTED]. Review of Resident R27's (MONTH) (YEAR) physician orders [REDACTED]. Review of Resident R27's (MONTH) (YEAR) Medication Administration Record [REDACTED] Observation of Resident R27 sitting in the Manheim House dining room on (MONTH) 26, (YEAR) at approximately 12:03 p.m. revealed a white medication tablet on the dining room table on top of the resident's place mat. Interview with Resident R27 on (MONTH) 26, (YEAR) at approximately 12:03 p.m. revealed that the resident was unable to identify the medication. Interview with licensed nursing staff, Employee E4 on (MONTH) 26, (YEAR) p.m. at approximately 12:07 p.m., indicated that the medication tablet was Resident R27's 12:00 p.m. [MEDICATION NAME] 500 mg. These findings were discussed with the Nursing Home Administrator on (MONTH) 30, (YEAR) at approximately 1:05 p.m. The facility failed to ensure that Resident R27 consumed all medications. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that nonpharmacological interventions were attempted prior to the use of as needed anti-psychotic medication for one of 18 residents reviewed (Resident R81). Findings include: Review of facility policy labeled PRN (as needed) Medication Documentation dated (MONTH) 20, (YEAR) revealed that proper documentation of the administration of PRN medication orders will assist in the clinical assessments of medication effectiveness. Procedure 2 states that nonpharmacological interventions must be offered to the resident prior to administering the PRN pharmacological medication (e.g. antianxiety, hypnotic, antipsychotic). These interventions may be documented in the clinical notes. Review of Resident R81 clinical record revealed an admitted (MONTH) 2, (YEAR) with a [DIAGNOSES REDACTED]. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of Resident R81's Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 30,2018 at approximately 1:30 p.m. with the Nursing Home Administrator confirming that there was no further documentation for non-pharmacological interventions were attempted prior to the administration of [MEDICATION NAME] 0.25 mg for (MONTH) 6 and 7, (YEAR). 28 Pa. Code 211.5(f) Clinical Records, 28 Pa. Code 211.12(d)(5) Nursing Services

Based on observation and staff interviews, it was determined that the facility failed to date a medication after open on one of four medication carts observed. (Medication cart #1) Findings include: Observation of medication cart #1contents on (MONTH) 30, (YEAR) at approximately 9:45a.m. revealed an open bottle of Latanoprost solution 0.005% eye drops, which was undated. The box read to discard contents six weeks after opening. Interview with licensed employee, Employee E5 on (MONTH) 30, (YEAR) at approximately 9:48am confirmed that the bottle was opened and should have been dated and initialed. Interview with licensed employee, Nurse manager, Employee E3 and Nursing Administrator on (MONTH) 30, (YEAR) at approximately 12:20p.m. confirmed the bottle of Latanoprost solution was opened and not dated, or initialed as it should have been. The facility failed to indicate the open date and initials on a medication found in the medication cart on Oregon North. 28 Pa Code 211.12(d)(1) Nursing Services

Based on review of facility policy, clinical record and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of 19 residents reviewed (Resident R84). Findings include: Review of facility policy, Provider Calling Procedure, revised (MONTH) 19, (YEAR), revealed that the nurse is expected to notify the provider when there is an acute or sudden change in the resident's condition. Review of Resident R84's nursing note dated (MONTH) 17, (YEAR), revealed that resident had an episode of emesis after eating her lunch too fast and was unresponsive for 10-15 minutes. Further review of the resident's R84's clinical record revealed no evidence that the physician was made aware of this change in condition. Interview on (MONTH) 31, (YEAR), at 1:07 p.m. with the Nursing Home Administrator confirmed that there was no evidence that the physician was notified of Resident R84 episode of emesis and unresponsiveness that occurred on (MONTH) 17, (YEAR). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1) Nursing services

Based on review of facility documentation and staff interviews, it was determined that the facility failed to report an allegation of sexual abuse to the State survey agency for one of two residents reviewed (Resident R1). Findings include: Review of the Older Adults Protective Services Act (OAPSA), mandates reporting requirements on suspected abuse. Any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local Area Agency on Aging and licensing agencies. If the suspected abuse is sexual abuse, serious physical injury, serious bodily injury, or suspicious death as defined under OAPSA, the law requires additional reporting to the Department of Aging and local law enforcement. Review of electronic event report submitted to State agency revealed that on November 26, 2016, Resident R1 made an allegation of sexual abuse. Resident R1 was transferred to the local hospital for further evaluation. There was no documented evidence in the facility event report that Pennsylvania Department of Aging (PDA) was notified of the resident allegation sexual abuse as required by the State Law. Interview with Nursing Home Administrator on January 6, 2017 at 9:00 a.m. revealed that the facility did not notify the Pennsylvania Department of Aging (PDA) of the allegation of sexual abuse involving the resident. The facility failed to report an incident of sexual abuse alleged by Resident R1 to the Pennsylvania Department of Aging as required by the state law. Pa Chapter 51 Code 51.3(g)(6) Notification 28 Pa Code 201.14(a)(c) Responsibility of licensee 28 Pa Code 201.18(b)(1)(d) Management 28 Pa Code 201.29(d) Resident rights 28 Pa Code 211.12(c) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store and maintain a dumpster in a sanitary manner. Findings include: Observation during the environmental tour, accompanied by the Director of Maintenance, on March 16, 2016 at approximately 9:00 a.m., revealed a dumpster with the lid not closed due to the overflow of trash bags. Interview with the Director of Maintenance at the time of the observation confirmed that the dumpster was not closed due to overfilling. F372 483.35(i)(3) Disposal of Garbage and Refuse Properly 28 PA Code 201.14(a) Responsibility of licensee 28 PA Code 201.18(b)(3) Management 28 PA Code 207.2(a) Administrator's responsibility

Based on clinical record review and staff interview, it was determined that the facility failed to assure that resident assessments accurately reflect the resident's current status in the areas of pain, behavior and falls (Residents: A8, A14, E3, CL3). Findings include: Review of Resident A8's significant change Minimum Data Set (MDS- Periodic assessment of resident needs), dated August 16, 2015, revealed section J0200 title- Should Pain Assessment Interview be Conducted? and section J0700- title Should the Staff Assessment for Pain be Conducted? were coded with dashes (-) and not coded with either a 1 or a 0 to indicate which kind of interview should be conducted, interview with licensed nursing staff, Employee E3 confirmed that these sections were coded incorrectly with dashes. Review of Resident A14's Annual MDS, dated [DATE], revealed under section E0800- title Rejection of Care-Presence & Frequency and section E1000- title Wandering- Impact were coded with dashes (-) and did not indicate the frequency and severity of the behaviors. Review of Resident E3's admission assessment, dated December 8, 2015, revealed that a dash was entered in Section E0800 related to rejection of care, when the response should either have been 0 for behavior not exhibited, 1 for behavior occuring 1 to 3 days, 2 for behavior occuring 4 to 5 days and 3 for behavior occuring daily. Review of Resident CL3's admission assessment, dated January 15, 2016, revealed that dashes were entered for Section J1700 title Fall History on Admission. Interview with licensed staff, Employee E3 on March 16, 2016 at approximately 12:00 p.m. confirmed that these sections for the aforementioned residents were not coded accurately. 28 PA Code 201.18(b)(1) Management Previously cited 2/18/2015 28 PA Code 211.5(f) Clinical records Previously cited 2/18/2015 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 2/18/2015

Based on the clinical record review, and interview with facility staff, it was determined the facility failed to accurately assess one of 21 resident reviewed (Resident G11) Findings include: Review of Resident G11 ' s quarterly Minimum Data Set (MDS- assessment of resident care needs and status) dated May 12, 2014 had a reference date (look back period) of April 30, 2014. Under section G 120A Functional Status, Bathing -self performance- How the resident takes a full body bath/shower and transfers in /out of tub/shower, was coded as 8 (activity did not occur). The resident was also coded as " 8 " under section 120 B- bathing support provided, meaning bathing did not occur. During an interview with licensed nurse, Employee E4 and the Director of Nursing on February 18, 2015 at 1:30p.m., it was confirmed by Employee E4 that this section of the assessment was not accurately coded. 28 Pa. Code: 211.5 (f) Clinical Records. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on a review of clinical records, facility policy and staff interview, it was determined that the facility failed to ensure care and services to restore or improve bladder function for three out of 21 residents reviewed ( Residents C16, G11 and G15). Findings include: Review of the facility ' s policy for urinary incontinence reviewed May 2014 revealed its policy revealed that urinary incontinence is not a normal part of the aging process. Because urinary incontinence is a symptom of a condition and may be reversible, it is important to understand the causes and address incontinence to the extent possible. It revealed residents who are incontinent of urine are identified, assessed and given appropriate treatment and services to achieve or maintain as much normal urinary function as possible. It revealed residents will also be assessed for incontinency quarterly and annually and for residents who have a change in their continence status. It revealed the restorative team will review 7 days of information documented in the electronic record completed by the caregiver. The physician will complete the incontinency/physician order [REDACTED]. It indicated the household team leader and restorative team will update the care plan as needed. The care plans are also reviewed at least every 90 days. Review of Resident C16 ' s quarterly Minimum Data Set (MDS - an assessment of resident care needs and status) dated June 9, 2014 with assessment reference day of June 1, 2014, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 reflecting that the resident was moderately impaired for decision making, needed assistance of staff for transfer, needed set up help for ambulation, was frequently incontinent of bladder and had no trial of toileting program attempted. Review of Resident C16 ' s bladder assessment dated [DATE] revealed that the resident was incontinent throughout the seven day bladder assessment and staff will continue with taking the resident to the bathroom upon request. Review of Resident C16 ' s bladder assessment dated [DATE] also revealed that the resident continued to be incontinent and will inform staff when she must use the bathroom and to continue with upon request toileting. Review of Resident C16 ' s annual MDS assessment dated [DATE], revealed that Resident G15 needed assistance of staff for transfer and for ambulation, and continued to be frequently incontinent of bladder and had no trial of toileting program attempted Review of the resident ' s care plan for urinary incontinence with effective date of July 1, 2013 revealed an intervention for the team to establish a regular toileting routine. Review of Resident C16 ' s care summary revealed resident was incontinent of bladder; the plan was to toilet upon request. There was no documented evidence that a toileting pattern had been established to help the resident restore as much bladder continence as possible. On February 18, at approximately 11:00 a.m. a request was made to review Resident C16 ' s point of care electronic bowel incontinency records for the periods of assessments listed above and a request was again made to the DON at approximately 1:00 p.m. that day. No documentation was made available for review. Review of the Resident G15 ' s quarterly Minimum Data Set (MDS- assessment of resident status and care needs dated July 15, 2014, revealed that the resident had a BIMS score of 9 out of 15 reflecting that the resident was moderately impaired for decision making needed set up help with transfer and assistance of staff for ambulation, hygiene frequently incontinent of bladder and had no trial of toileting program attempted. Review of the resident ' s bladder assessment dated [DATE] revealed that the resident had increased number of continent episodes, wears pull ups with liners during waking hours and briefs at hour of sleep and was independent with hygiene checks, often refused assistance with toileting and staff would re -approach at a later time. Review of Resident G15 ' s annual assessment dated [DATE] with assessment reference day of October 5, 2014, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 reflecting that the resident was cognitively intact for decision making, needed assistance of staff for transfer, for ambulation, for hygiene, was frequently incontinent of bladder and had no trial of toileting program attempted. Review of Resident G15 ' s bladder assessment dated [DATE] revealed that the resident was mostly incontinent during the assessment period and independent with hygiene checks and will continue with routine to keep dry and comfortable as he allows. Review of the Resident G15's quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 9 out of 15 reflecting that the resident was moderately impaired for decision making continues to be frequently incontinent of bladder. Requests for facility electronic documentation for point of care regarding Resident G15 ' s incontinence for the periods of assessment listed above made with licensed Employee E 6 on February 18, 2015 at approximately 11:00 a. m. and with the Director of Nursing at approximately 1:00 p.m. revealed no document available for review. Review of Resident G11 ' s assessment dated [DATE] with assessment reference day of July 22, 2014, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14 out of 15 reflecting that the resident was cognitively intact for decision making, needed assistance of staff for activities of daily living was frequently incontinent of bladder and had no trial of toileting program attempted. Review of Resident G11 ' s bladder assessment dated [DATE] revealed for the assessment period of July 16-22, 2014, urinary incontinence episodes increased and the resident ' s continent episodes decreased. It revealed that the resident is able to make needs known therefore will continue with upon request routine. Review of the activities of daily living verification worksheet from July 16-22, 2014 revealed that staff documented mainly once a shift and occasionally more than once a shift during the seven referenced days above making it difficult to determine a voiding pattern. Review of the Resident G11 ' s quarterly assessment dated [DATE], revealed that the resident had a BIMS score of 8 out of 15 reflecting that the resident was moderately impaired for decision making, needed assistance of staff for transfer and for ambulation, and continued to be frequently incontinent of bladder and had no trial of toileting program attempted. However, Resident G11 ' s bladder assessment dated [DATE] revealed that the resident was alert and oriented, able to make needs known and urinary incontinent episodes increased, urinal placed at bedside and will toilet upon request. Review of Resident G11 ' s s care summary for Resident G11 dated January 20, 2015 revealed toileting plan upon request as resident allows. Review of Resident G11 ' s care plan for urinary incontinence with effective date of June 27, 2013 revealed an intervention for the team to complete a 3 bladder assessment and team would establish a regular toileting routine while awake. Requests for facility electronic documentation for point of care regarding Resident G11 ' s incontinence for the periods of assessment listed above made with licensed Employee E 6 on February 18, 2015 at approximately 11:00 a. m. and with the Director of Nursing at approximately 1:00 p.m. revealed no document available for review. Interview with nursing Employee E5 in the company of the Director of Nursing on February 18, 2015 at approximately 1:30 p.m. revealed that staff are trained to document continence on the point of care when care was provided but was not certain if staff document once every shift or at the time that care was provided. The facility failed to ensure Residents C16, G11 and G15 bladder function were evaluated to determine a continence pattern during the residents ' continence evaluations and as per care plans to help restore as much bladder function as possible for the above listed residents. 28 Pa. Code: 211.5(f) Clinical records Previously cited 1/27/2014, 7/28/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 1/27/2014, 7/28/14 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 1/27/2014, 7/28/14

Based on facility policy and procedure review, clinical record review, and staff interview it was determined the facility failed to obtain accurate heights for three of 21 residents reviewed and provided care and services related to bowel continence for one of 21 residents reviewed (Residents: B5, E1, F9 and C16) Findings Include: Review of facility policy and procedure titled Weighing and Measuring the Height of a Resident, last reviewed on May 30, 2014, revealed the height is obtained upon admission and annually. Under procedure, the policy stated to place the resident in the bed with the legs extended as much as possible. Measure the resident from the heel to the top of the head. Record the figure as the resident ' s height on the admission nursing assessment or the vitals tab in the electronic medical record. Review of Resident B5's heights revealed on July 12, 2013 the resident's height was recorded as 68 inches. On the annual assessment dated [DATE] the resident's height was recorded as 63 inches, a re-height taken on June 11, 2014 was recorded as 69 inches revealing a variation in Resident B5's height. On November 20, 2014 the quarterly assessment recorded the height as 69 inches. Interview with licensed nurse, Employee E3 on February 17, 2014 at approximately 2:15 p.m. , confirmed the discrepancy in the height of Resident B5. Employee E3 confirmed the height of 63 inches recorded June 10, 2014 which was obtained for the annual assessment of June 10, 2014 was the height used for the annual assessment. Interview with the director of nursing (DON) on February 18, 2014 at approximately 11:30 a.m., confirmed the height of 63 inches was incorrect. Review of Resident E1's heights revealed on May 18, 2014, the resident ' s height was recorded as 63 inches; on August 23, 2014, it was recorded as 55 inches; on November 19, 2014, it was recorded as 61 inches, and on December 26, 2014, it was recorded as 59 inches. Review of resident F9's heights revealed on August 12, 2013 the height was recorded as 67 inches; on August 9, 2014 it was recorded as 62 inches. Interview with licensed nurse, Employee E3 February 18, 2014 at 10:38 a.m. confirmed that these residents had not had a re-height completed to confirm the discrepancies in height and that these heights could not have been accurate due to the significant differences in height. Review of the facility ' s policy for bowel incontinence reviewed May 2014, revealed its policy stated that residents who are incontinent of bowel are identified, assessed and given appropriate treatment. It revealed that residents are assessed for incontinency quarterly and annually and residents who have a change in their continence status. It revealed the resident will have an electronic and paper seven day bladder report. It revealed the restorative team will review 7 days of information documented in the electronic record by the caregiver. The restorative team will collect and review the information as listed on the restorative aide bowel assessment summary, talk with caregivers, and will enter a summary into the electronic medical record. The resident ' s continence intervention program will be updated and revised as needed and the use of continence products, and update resident care summary. The household team leader and restorative team will update the care plan as needed. It revealed the care plans are also reviewed at least every 90 days. Review of Resident C16 ' s care plan for bowel incontinence effective July 1. 2013 revealed team members will establish a pattern for bowel movements. There was no documentation that a pattern of bowel movements had been established. Review of Resident C16 ' s Quarterly Minimum Data Set (MDS - an assessment of resident care needs and status) dated June 9, 2014, with assessment reference day of June 1, 2014, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 reflecting that the resident was moderately impaired for decision making, needed assistance of staff for transfer, needed set up help for ambulation, was frequently incontinent of bowel and had no trial toileting program attempted. . The bowel assessment dated [DATE] revealed that the resident had no bowel incontinence during the 7 day look back period Review of Resident C16 ' s bowel assessment dated [DATE] also revealed that the resident had no bowel incontinence in the 7 day look back period. Resident C16 ' s bowel assessment indicated to continue upon request, toileting since resident was continent of bowel throughout the 7 day assessment period. Review of Resident C16 ' s annual MDS dated [DATE], revealed that the needed assistance of staff for transfer and for ambulation, continued to be frequently incontinent of bowel and had no trial of toileting program attempted Review of Resident C16 ' s care summary bowel assessment dated [DATE] revealed that the resident was incontinent of bowel and there were no interventions indicated. Review of the resident's current care plan for bowel incontinence revealed team members will establish a pattern for bowel incontinence. There was no documentation that a pattern of bowel incontinence had been established. On February 18, at approximately 11:00 a.m. a request was made to review the point of care electronic bowel incontinency records for the periods of assessments listed above and a request was again made to the DON at approximately 1:00 p.m. that day. No documentation was made available for review. Interview with nursing staff, Employee E 5 in the company of the Director of Nursing (DON) on February 18, 2015 at approximately 1:30 p.m. revealed that staff are trained to document on the point of care electronic record when care is provided but it was not certain if staff document once every shift or at the time that care was provided. The facility failed to determine the pattern of Resident C16 ' s bowel incontinence to help regain as much bowel function as possible as per care plan. 28 Pa. Code: 211.5(f) Clinical records Previously cited 1/27/2014, 7/28/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 1/27/2014, 7/28/14 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 1/27/2014, 7/28/14

Based on a review of facility policies, literature regarding medications, clinical records review and staff interview, it was determined that the facility failed to follow physician orders and established policy for reporting blood sugar levels to the physician, documenting treatment provided for [DIAGNOSES REDACTED] and consulting with the physician concerning the administration of anti-diabetic medications resulting in harm to one of two residents reviewed. (Resident R1) Findings include: Review of the facility policy entitled Blood Glucose Monitoring (dated July 2011) revealed that [DIAGNOSES REDACTED] is defined as a blood glucose level of less than 60 and symptoms include altered consciousness, [MEDICAL CONDITION](rapid heart rate), increased respirations, and cool and clammy skin. Review of the facility policy entitled Medication Administration (revised November 6, 2013) revealed that if a blood glucose is less than 60 or the resident has symptoms of [DIAGNOSES REDACTED], insulin should be held and the physician notified. Orange juice with sugar or oral glucose gel can be given if the resident is alert enough to swallow. The policy does not provide direction for treatment if the resident is unresponsive. Review of Resident R1 ' s clinical record in the [DIAGNOSES REDACTED]. Review of Resident R1 ' s quarterly Minimum Data Set (MDS - a periodic assessment completed to identify the resident ' s status and care needs) dated May 18, 2014 revealed that the resident had a BIMS score (Brief Interview for Mental Status) of 1 (one) indicating severe cognitive impairment. Review of Resident R1 ' s care plan dated February 15, 2014 directed staff to report any symptoms of [DIAGNOSES REDACTED] to the physician. Review of physician orders revealed an order on February 24, 2014 to check the resident ' s blood sugar by accucheck (a blood sugar testing device which deploys a lancet needle to allow a small amount of blood to be squeezed onto a strip in the monitor to determine blood glucose level) on Monday, Wednesday and Friday at 6:00 a.m. In addition, a nursing measure included in the order directed staff to follow the facility protocol for notifying the physician of blood glucose results. The physician order for [REDACTED]. A physician ' s order on April 30, 2014 revealed an order for [REDACTED]. The Geriatric Dosage Handbook (2011) stated that this medication should be given with the first bite of each meal. The physician orders also revealed that the resident was also taking [MEDICATION NAME] ER (an oral diabetic medication for blood glucose management started February 14, 2014) 5 milligrams twice a day. The Geriatric Dosage Handbook literature states that the extended release [MEDICATION NAME] should be given with breakfast. Review of a faxed communication sheet to the physician dated May 13, 2014, requested the physician to review Resident R1 ' s blood glucose levels for May 2 through May 12, 2014 at the request of the staff nurse. In the communication to the physician, the nurse indicated that the resident never had observed symptoms of [DIAGNOSES REDACTED]; however, the blood glucose levels were low on May 2, 2014 (64), May 5, 2014 (62) and May 9, 3014 (64). On May 12, the resident was hypoglycemic at 47 and received chocolate milk. The physician ordered the [MEDICATION NAME] decreased to 10 units on May 13, 2014. In addition, the resident had a respiratory infection at this time and was receiving an anti-infective, Levoquin which could have altered glucose levels. Review of the Medication Administration Record [REDACTED].m on May 12, 2014 There was no documentation that the nurse checked with the physician for direction about administering these medications following the low blood glucose obtained at 5:30 a.m. on May 12, 2014 Review of the blood glucose accucheck test results for June 2014 in the data section of the clinical record revealed that the resident ' s blood glucose on June 9, 2014 at 6:00 a.m. was 54. There was no documentation that the physician was notified of this low blood glucose or consulted concerning the administration of [MEDICATION NAME] ER and [MEDICATION NAME] as documented as given June 9, 2014 in the Medication Administration Record [REDACTED]. Review of the blood glucose results for June 2014 on the data section revealed that the resident ' s blood glucose on June 23, 2014 at 5:45 a.m. was 54. There was no documentation that the physician was notified of this low blood glucose level or consulted concerning the administration of [MEDICATION NAME] ER and [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED] On June 27, 2014 a fax communication to the physician indicated that the resident ' s blood glucose at 5:30 a.m. was measured at 29 on the right hand (which was described as cool) and repeated in the left hand and found to be 43. Documentation in administration notes indicated that the resident was given ice cream. The physician order dated June 27, 2014 discontinued the medication, [MEDICATION NAME], however the resident did receive both [MEDICATION NAME] and [MEDICATION NAME] ER at 9:00 a.m.and [MEDICATION NAME] at 1:00 p.m.on June 27th according to the June 2014 medication administration record. There was no documentation that staff consulted with the physician before administering the medications following the low blood glucose at 5:30 a.m. On June 30, 2014 Resident R1 ' s blood glucose accucheck level was documented at 55 at 5:38 a.m. Review of the Medication Administration Record [REDACTED] Review of the meal percentage documentation for June 30, 2014 indicated that the resident did not eat breakfast. There is no documentation that the physician was notified of the 55 accucheck blood glucose level on June 30,2014 and consulted about the [MEDICATION NAME] administration since it should be given with a meal. There is no documentation relating what the staff did to address the resident ' s [DIAGNOSES REDACTED]. Interview with licensed nurse Employee E4 on July 28, 2014 at 1:30 p.m. confirmed that the facility failed to follow facility policy and had not notified the physician of [DIAGNOSES REDACTED] on June 9, June 23 and June 30, 2014 and failed to document the treatment given to the resident on June 9, 2014 and June 30, 2014. On July 1, 2014 the progress notes indicated that the resident was found at approximately 11:00 a.m. with slurred speech, drooping mouth and inability to respond verbally to staff and family. Resident R1 ' s blood glucose level was determined to be 31. Review of the Medication Administration Record [REDACTED]. Review of the meal intake records for June 30, 2014 indicated that the resident had only consumed half of the luncheon and supper meals the day before and had eaten no evening snack. The resident had received [MEDICATION NAME] 10 units SQ at 8:00 p.m. the previous night. Interview with nursing staff Employee E1 a CNA on July 28, 2014 at 11:00 a.m. revealed that the resident is offered breakfast but has often refused preferring to sleep late. The employee was unaware of any procedure for letting the nurse know that the resident refused breakfast and stated that it is because residents have individualized care and are allowed to refuse care. During an interview on July 28, 2014 at 2:45 p.m., the DON was unable to provide any facility policy to direct staff in monitoring meal and snack intake for residents at risk for hypoglycemic episodes to assure appropriate care while respecting the right to refuse. The DON did confirm that the physician should have been consulted regarding the administration of anti-diabetic medications ([MEDICATION NAME] and [MEDICATION NAME]) when the resident had an accucheck that indicated [DIAGNOSES REDACTED] or when the resident did not eat breakfast. The facility failed to follow facility policy, physician orders and the established resident care plan in reporting episodes of [DIAGNOSES REDACTED] and failure to eat to the physician. The facility failed to document treatment provided to the resident to address [DIAGNOSES REDACTED]. In addition, the facility failed to hold a medication used to lower blood glucose and consult with the physician when the blood glucose level obtained indicated the resident was hypoglycemic or when the resident refused the meal resulting in actual harm to Resident R1 a cognitively impaired resident. 28 PA Code: 211.5(f) Clinical records Previously cited 1/27/2014, 2/12/2013 28 PA. Code 211.10(d) Resident care policies Previously cited 1/27/2014, 2/12/2013 28 PA Code: 211.12(d)(1)(5) Nursing services Previously cited 1/27/2014, 2/12/2013