Every finding on record at Lecom at Snyder Memorial

Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for 22 of 26 Residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, R13, R14, R18, R20, R23, R26, R36, R49, R59, R76, and R85). Findings include: Facility policy entitled Physician Visits dated 5/13/26, revealed The attending physician must make visits in accordance with applicable state and federal regulation. The attending physician must visit his/her patient at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. and A physician visit is considered timely if it occur not later than ten (10) days after the date the visit was required. However, the subsequent visit must be timed in relation to when the previous one was due, not to when it was made. Review of Medical Director Agreement dated 9/16/26, indicated Duties and Responsibilities of a Medical Director: Coordinate and oversee medical care and treatment, including physician services.Monitor provision of physician services to provide services to meet the highest practicable physical, mental, and psychosocial well-being of each resident.Frequency of physician visits Resident R1's clinical record revealed an admission date of 10/7/25, with diagnoses that included benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), transient ischemic attack (TIA - occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and dementia (loss of cognitive functioning affecting a person's memory and behaviors). Resident R1's clinical record revealed physician progress note dated 12/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 12/5/25, and 3/10/26, a span of 95 days. Resident R2's clinical record revealed an admission date of 7/19/24, with diagnoses that included schizoaffective disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]), Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), and dementia. Resident R2's clinical record revealed physician progress note dated 9/26/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/26/25, and 3/10/26, a span of 165 days. Resident R3's clinical record revealed an admission date of 6/16/23, with diagnoses that included dementia, hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat). Resident R3's clinical record revealed physician progress note dated 3/6/26. The clinical record lacked evidence of any physician progress notes being completed since the 3/6/26 visit, which is greater than the required 60 days (70 days including the 10-day grace period). Review of Resident R4's clinical record revealed an admission date of 12/23/24, with diagnoses that included Paraplegia (a condition where a person is paralyzed from the waist down), acute kidney failure (a sudden loss of the kidney's ability to filter waste products and extra fluid from the body), and idiopathic hypotension (a condition with abnormally low blood pressure without a known cause). Resident R4's clinical record revealed physician progress note dated 12/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 12/5/25, and 3/10/26, a span of 95 days. Review of Resident R5's clinical record revealed an admission date of 10/23/23, with diagnoses that included seizure (a sudden, temporary disruption in the brains normal electrical activity that can cause symptoms such as changes in movement jerking or twitching, changes in awareness such as staring or loss on consciousness), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Resident R5's clinical record revealed physician progress note dated 10/29/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 10/29/25, and 3/10/26, a span of 132 days. Review of Resident R6's clinical record revealed an admission date of 12/21/12, with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where urine cannot properly drain from the kidney due to blockage), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Resident R6's clinical record revealed physician progress note dated 10/7/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/7/25, and 3/6/26, a span of 150 days. Resident R7's clinical record revealed an admission date of 10/10/19, with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), diabetes (a health condition caused by the body's inability to produce enough insulin), and TIA. Resident R7's clinical record revealed physician progress note dated 9/19/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/19/25, and 3/10/26, a span of 172 days. Review of Resident R8's clinical record revealed an admission date of 3/9/26, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that causes impaired thinking process with episodes of extreme mood swings with emotional highs and emotional lows), hypertension, and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Resident R8's clinical record lacked any evidence of a physician progress note being completed at least once every thirty (30) days for the first ninety (90) days after Resident R8's admission. Resident R9's clinical record revealed an admission date of 10/18/12, with diagnoses that included schizoaffective disorder, gastroesophageal reflux disease (GERD-happens when stomach acid flows back up into the esophagus and causes heartburn), and dysphagia (a medical condition characterized by difficulty swallowing solids, liquids, or both, which can lead to choking, coughing, or the sensation of food being stuck in the throat). Resident R9's clinical record revealed physician progress note dated 9/19/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/19/25, and 3/6/26, a span of 168 days. Resident R10's clinical record revealed an admission date of 11/19/18, with diagnoses that included dysphagia, intellectual disabilities, and impulse disorder. Resident R10's clinical record revealed a physician progress note dated 11/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/5/25, and 3/10/26, a span of 125 days. Resident R11's clinical record revealed an admission date of 5/22/24, with diagnoses that included bi-polar disorder (a lifelong mental condition that causes extreme changes in mood and activity), anxiety, and depression. Resident R11's clinical record revealed a physician progress note dated 11/5/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/5/25, and 3/10/26, a span of 125 days. Resident R12's clinical record revealed an admission date of 3/5/11, with diagnoses that included dementia, hypertension, and diabetes. Resident R12's clinical record revealed a physician progress note dated 10/3/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/3/25, and 3/6/26, a span of 154 days. Review of resident R13's clinical record revealed an admission date of 7/20/23, with diagnoses that included quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and edema (swelling to an area of body due to holding excessive fluid). Resident R13's clinical record revealed physician progress note dated 9/8/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/8/25, and 3/6/26, a span of 179 days. Review of Resident R14's clinical record revealed an admission date of 5/14/25, with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), hyperlipidemia (high cholesterol), and gastro esophageal reflux disease. Resident R14's clinical record revealed physician progress note dated 10/2/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/2/25, and 3/6/26, a span of 155 days. Resident R18's clinical record revealed an admission date of 1/9/26, with diagnoses that included anxiety, depression, and dementia. Resident R18's clinical record revealed a physician progress note dated 3/6/26, and then again on 4/14/26. The clinical record lacked evidence of any physician progress notes being completed upon admission at least once within the first 30 days. Review of Resident R20's clinical record revealed an admission date of 11/1/23, with diagnoses that included gastro esophageal reflux disease, hypertension, and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs). Resident R20's clinical record revealed physician progress note dated 10/29/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 10/29/25, and 3/10/26, a span of 132 days. Resident R23's clinical record revealed an admission date of 12/26/25, with diagnoses that included panic disorder, hypertension, and depression. Resident R23's clinical record revealed physician progress note dated 3/6/26. The clinical record lacked evidence of any physician progress notes being completed upon admission within the first 30 days, again at 60 days, and since the 3/6/26 visit, which is greater than the required 60 days (70 days including the 10-day grace period). Resident R26's clinical record revealed an admission date of 7/6/23, with diagnoses that included diabetes, hypertension, and atrial fibrillation. Resident R26's clinical record revealed a physician progress note dated 10/1/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 10/1/25, and 3/6/26, a span of 156 days. Resident R36's clinical record revealed an admission date of 1/25/25, with diagnoses that included COPD, diabetes, and osteoporosis (a condition where bone strength weakens and is susceptible to breaking). Resident R36's clinical record revealed a physician progress note dated 9/8/25, and then not again until 3/6/26. The clinical record lacked evidence of any physician progress notes being completed between 9/8/25, and 3/6/26, a span of 179 days. Resident R49's clinical record revealed an admission date of 3/10/25, with diagnoses that included paranoid schizophrenia (a type of severe brain disorder in which a person suffers from paranoia, hallucinations, and delusions), dysphagia, and anxiety. Resident R49's clinical record revealed a physician progress note dated 11/21/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 11/21/25, and 3/10/26, a span of 109 days. Resident R59's clinical record revealed an admission date of 2/6/26, with diagnoses that included dementia related to alcohol abuse, anxiety, and depression. Resident R59's clinical record revealed a physician progress note dated 3/6/26, and then again on 4/14/26. The clinical record lacked evidence of any physician progress notes being completed since the 4/14/26, visit which is greater than the required 90 days following and admission. Resident R76's clinical record revealed an admission date of 10/9/25, with diagnoses that included hypothyroidism (thyroid does not produce enough hormones for the body), dysphagia, and dementia. Resident R76's clinical record revealed a physician progress note dated 11/21/25, and then again on 3/10/26. The clinical record lacked evidence of any physician progress notes being completed upon admission at least once within the first 30 days, at 60 days, at 90 days, and since the 3/10/26, visit which is greater than the required 60 days (70 days including the 10-day grace period). Resident R85's clinical record revealed an admission date of 9/1/22, with diagnoses that included COPD, osteoporosis, and schizoaffective disorder. Resident R85's clinical record revealed a physician progress note dated 9/26/25, and then not again until 3/10/26. The clinical record lacked evidence of any physician progress notes being completed between 9/26/25, and 3/10/26, a span of 165 days. During an interview on 5/29/26, at 11:40 a.m. the Director of Nursing confirmed that Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, R13, R14, R18, R20, R23, R26, R36, R49, R59, R76, and R85 clinical records lacked evidence of the required physician visit progress notes. He/she also confirmed that physician progress notes should be completed at every required visit. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on review of facility policy and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to appropriately discard outdated medications for one of two medications rooms (West) and one of four medication carts (West One). Findings include: Facility policy entitled Medication Labeling and Storage dated 5/13/26, revealed Multi-dose [NAME] that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30-days after opening. Review of manufacturer's guidelines revealed that and open vial of Insulin Glargine (also known as Lantus - medication used to treat diabetes) should be discarded within 28-days after opening. Observation of drug storage on 5/26/26, at 1:52 p.m. on the [NAME] Unit medication storage room refrigerator revealed an open vial of Tubersol with an open date of 3/23/26 making the discard date 4/22/26. During an interview at the time of observation, Licensed Practical Nurse (LPN) Employee E1 confirmed that the open vial of Tubersol was past 30 days and should have been discarded. Observation of drug storage on 5/26/26, at 1:55 p.m. of [NAME] One medication cart revealed an open vial of Insulin Glargine with an open date of 4/26/26 and discard date of 5/24/26. During an interview at the time of observation, LPN Employee E1 confirmed that the open vial of Insulin Glargine was past 28 days and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 26 residents reviewed (Residents R6 and R85).Findings include: Facility policy entitled Care Plans, Comprehensive Person-Centered dated 5/13/26, revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident R6's clinical record revealed an admission date of 12/21/12, with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (a condition where urine cannot properly drain from the kidney due to blockage), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Resident R6's progress notes revealed a note dated 2/12/26, indicated that his/her urinary catheter was removed. Resident R6's Care Plan for altered genitourinary system dated 12/16/25, revealed interventions to change urinary catheter as ordered, check tubing for kinks each shift, flush urinary catheter as ordered, catheter to continuous drainage, irrigate catheter, and secure catheter. Resident R6's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 5/11/26, Section H Bladder and Bowel revealed under H0100 Appliances indwelling catheter was answered no. Review of Resident R6's current physician orders revealed no current order for a urinary catheter. During an interview on 5/28/26, at 12:45 the Nursing Home Administrator confirmed that Resident R6's altered genitourinary system care plan was not reviewed/revised to reflect current resident care and services regarding the catheter. He/she also confirmed that care plans should be reviewed and revised as necessary. Resident R85's clinical record revealed an admission date of 9/1/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Osteoporosis (a condition where bone strength weakens and is susceptible to breaking) , and Schizoaffective Disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]). Resident R85's Care Plan for elopement risk related to history of attempts to leave facility unattended initiated 5/25/23, with target date of 6/30/26, revealed an intervention for Wanderguard Bracelet Check every shift for proper functioning initiated 5/25/23, with a last revision date of 6/2/25. Resident R85's MDS's with Assessment Reference Dates (7 day look-back period of time) of 7/31/25, 10/25/25, 1/23/26, and 4/1/26, Section P0220 Alarms Subsection E Wander / Elopement Alarms was coded as No for being used in the last. Resident R85's physician orders revealed an order dated 1/24/24, to discontinue wanderguard to right wrist. During an interview on 5/28/26, at 12:45 p.m. Licensed Practical Nurse Assessment Coordinator confirmed that Resident R85's wanderguard was discontinued on 1/24/24, and his/her care plan was not updated to accurately reflect that his/her wanderguard was discontinued and it should have been. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 26 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Care Plans - Baseline dated 5/13/26, revealed The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:The stated goals and objectives of the resident. A summary of the resident's medications and dietary instructions.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Review of Resident R1's clinical record revealed an admission date of 10/7/25, with diagnoses that included Asthma (a long-term lung disease that causes the airways to narrow and make it difficult to breath), hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and hypertension (high blood pressure). Resident R1's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R1 and/or his/her representative. During an interview on 5/28/26, at 3:11 p.m. the Nursing Home Administrator confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Resident R1 and/or their representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was prepared in a safe and sanitary manner in the dishwashing area of the main kitchen.Findings include: A facility policy entitled, Sanitization dated 5/13/26, revealed The food service area is maintained in a clean and sanitary manner .All utensils, counters, shelves, and equipment are kept clean. Observations conducted on 5/26/26, at approximately 10:40 a.m. of the main kitchen revealed one fan over the meal prep area and one fan in the dishwashing area with a thick layer of dust and a fuzzy substance. Interview conducted with the Kitchen Manager at that time confirmed that the one fan over the meal prep area and the one fan in the dishwashing area had a thick layer of dust and a fuzzy substance. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to dispose of trash in the garbage dumpster and failed to dispose of boxes in the recycling dumpster properly for two dumpsters observed outside of the building.Findings include:Facility policy entitled Sanitization dated 5/13/26, indicated Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster/compactors with lids.Observations on 5/26/26, at approximately 12:30 p.m. of the garbage dumpster revealed several bags of trash heaping out of the container and the lid could not be closed and the recycling dumpster revealed several boxes heaping out of the container and the lid could not be closed.During an interview on 5/26/26, at approximately 12:40 p.m. the Nursing Home Administrator confirmed that the garbage dumpster had several bags of trash heaping out of the container and the recycling container had several boxes heaping out of the container, and that both containers lids could not be closed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for seven of 21 residents reviewed (R8, R9, R13, R15, R41, R55, and R76). Findings include: Review of the October 2024 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding 0 for not used, 1 for used less than daily, and 2 for used daily. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included epilepsy, bipolar disorder, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R8's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R8 was to have bilateral one-half side rails for bed mobility every shift. An incident report dated 2/28/25, revealed Resident R8 sustained a fall and was transferred to the hospital and returned with staples to the head. A Quarterly MDS dated [DATE], under section J1900, revealed Resident R8 had zero falls with major injury. Observations between 5/5/25, and 5/8/25, revealed Resident R8 had two quarter-sized rails on the bed. Review of Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included heart disease, mood disorder, and anxiety. A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R9's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R9 was to have left, one-half side rails for bed mobility every shift. Observations between 5/5/25, and 5/8/25, revealed Resident R9 had one quarter-sized rail on the bed. Review of Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), paraplegia (paralysis of both legs and lower part of body), and pressure ulcers (wounds caused by prolonged pressure). A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R13's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R13 was to have bilateral one-half side rails for bed mobility every shift. Observations between 5/5/25, and 5/8/25, revealed Resident R13 had two quarter-sized rails on the bed. Review of Resident R41s clinical record revealed an admitted [DATE], with diagnoses that included atrial fibrillation (irregular heartbeat), heart failure, and alcohol abuse with alcohol induced psychotic disorder. A Quarterly MDS dated [DATE], under Section P0100A, indicated that Resident R41's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R41 was to have one-half side rails two times a day for transfer. Observations between 5/5/25, through 5/8/25, revealed Resident R41 had two quarter-sized rails on the bed. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), anxiety, and diabetes (a health condition that caused by the body's inability to produce enough insulin). A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R15's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R15 was to have bilateral one-half side rails for bed mobility every shift. Observations between 5/5/25, through 5/8/25, revealed Resident R15 had two quarter-sized rails on the bed. Review of Resident R55's clinical record revealed an admitted [DATE], with diagnoses that included pyschotic disorder, mood disorder, and profound intellectual disabillities. A Quarterly MDS dated [DATE], under Section P0100B, revealed that Resident R55 was coded as trunk restraint not used. A physician's order dated 4/16/25, indicated that Resident R55 had an order for PSD (pelvic safety device) in SBC (straight back chair) for periods of low stimulation and calm during mealtimes, check and release every two hours and as needed for 15 minutes. Observations between 5/5/25, and 5/8/25, revealed Resident R55 had a PSD on while up in chair. Review of Resident R76's clinical record revealed an admitted [DATE], with diagnoses that included bipolar disorder, blindness in one eye, high blood pressure and anxiety. A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R76's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R76 was to have left one-half side rails for bed mobility every shift. Observations between 5/5/25, and 5/8/25, revealed Resident R76 had one quarter-sized rail on the bed. During an interview on 5/7/25, at 12:45 p.m. the Director of Nursing confirmed that Residents R8, R9, R13, R15, R41, R55, and R76 MDS's Section P0100A as listed above were coded incorrectly and the quarter-sized rails were not used as restraints. During an interview on 5/7/25, at 1:45 p.m. the Nursing Home Administrator confirmed that Resident R8's MDS Section J1900 was coded incorrectly regarding falls with major injury. 28 Pa. Code 211.5(f)(i)(ii)(ix) Medical records

Based on review of facility policies and clinical records, observations, staff interviews, and resident interview, it was determined that the facility failed to maintain proper infection prevention and control isolation by failing to remove isolation precautions for non-transmittable diseases which were confirmed by laboratory testing for three of five residents reviewed on droplet precautions (a type of transmission based precautions used to prevent the spread of respiratory infections) (Residents R56, R77, and R33). Findings include: Review of the facility policy entitled Policy on Isolation and Infection Precautions dated 4/1/25, revealed when it is determined that a resident needs isolation or special infection precautions to prevent the spread of infection, the appropriate isolation and/or precautions are utilized. Review of the facility policy entitled Infection Prevention & Control Program dated 4/1/25, revealed prevention of spread of infections is accomplished by the use of Standard and Transmission based precautions and other barriers, appropriate treatment and follow-up .Transmission based precautions chosen based on circumstances and are least restrictive as possible. Review of Resident R56's clinical record revealed an admitted [DATE], with diagnoses that included neuralgic amyotrophy (nerve damage and muscle wasting that causes severe pain), anxiety, depression, and other seasonal allergic rhinitis. Review of Resident R56's clinical record revealed progress notes dated 4/21/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Progress notes on 5/1/25, revealed he/she was tested for flu and COVID in the emergency room , which were both negative. Clinical record vitals indicated that Resident R56 remained afebrile (free of fever). Resident R56's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact). Interview conducted with Registered Nurse Employee E2 on 5/5/25, at approximately 2:00 p.m. revealed Resident R56 was on droplet precautions and he/she was unaware of any positive testing that would require droplet isolation. Interview conducted with Resident R56 on 5/6/25, at approximately 9:30 a.m. revealed he/she is very dissatisfied with the isolation precautions because all testing has been negative. He/she prefers to be out and about to socialize, but is uncomfortable wearing a mask, therefore he/she stays in his/her room. Review of Resident R77's clinical record revealed an admitted [DATE], with diagnoses that included dementia (thinking and social symptoms that interfere with daily living), weakness, pulmonary embolism (blood clot in lung), and dysphagia (difficulty swallowing). Review of Resident R77's clinical record revealed progress notes dated 4/29/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Clinical record vitals indicated that Resident R77 remained afebrile. Review of Resident R33's clinical record revealed an admitted [DATE], with diagnoses that included dementia, anxiety, dysphagia, and hypertension (high blood pressure). Review of Resident R33's clinical record revealed progress notes dated 4/29/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Clinical record vitals indicated that Resident R33 remained afebrile. Interview conducted with Licensed Practical Nurse (LPN) Employee E1 on 5/6/25, at 9:06 a.m. revealed Residents R56, R77, and R33 are generally not in their rooms. He/she indicated Resident R56 is alert and oriented and enjoys socializing, which is beneficial due to Resident R56 becoming more depressed related to some new diagnoses. LPN Employee E1 indicated Residents R77 and R33 are always brought out of their rooms and into the living room for stimulation and socialization and have not been able to do so related to the isolation. During an interview on 5/6/25, at approximately 10:45 a.m. the Infection Control Infection Preventionist confirmed that Residents R56, R77, and R33's testing for transmittable diseases were negative and that isolation should have been discontinued at that time. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of 25 residents reviewed (Resident R34). Findings include: Review of facility policy entitled Oxygen Administration dated 4/1/25, indicated Check physician's order for liter flow . Review of facility policy entitled Documentation, Clinical dated 4/1/25, indicated Documentation shall be done by nursing staff according to the needs of the resident and the care provided. Review of Resident R34's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R34's physician's orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) 2-3LPM (liters per minute) continuous, goal sats (oxygen saturation percent) 88-92%, dated 10/14/23. Review of Resident R34's oxygen saturation documentation revealed it lacked evidence that his/her oxygen saturation was obtained routinely to know if he/she was within his/her oxygen goal sats per physician orders. During an interview on 5/7/25, at 1:40 p.m. the Director of Nursing (DON) confirmed that Resident R34's clinical record lacked evidence of his/her oxygen saturation percentages to ensure that he/she was within his/her oxygen goal sats. He/she also confirmed that Resident R34's oxygen saturation levels should be monitored to ensure he/she is within his/her oxygen goal sats per physician orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 21 residents reviewed (Resident R34). Findings include: Review of facility policy entitled Care Plans dated 4/1/25, indicated The care plan will be reviewed, evaluated and updated with any significant change ., and Care plans will outline resident's care needs based on . physician orders . Review of Resident R34's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R34's physician orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen delivery) 2-3LPM (liters per minute) continuous, goal sats (oxygen saturation percent) 88-92%, dated 10/14/23. Review of Resident R34's care plans revealed a plan of care for recent history of tracheostomy with interventions for oxygen via nasal cannula at 2L PRN (as needed), and a plan of care for ADL self-care deficit with an intervention of oxygen at 2L via nasal cannula continuously. During an interview on 5/7/25, at 1:40 p.m. the Director of Nursing (DON) confirmed the care plans for Resident R34's oxygen were not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility records and staff interview, it was determined that the facility failed to ensure required attendance of the Director of Nursing and Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for two of four quarterly QAPI Committee meetings. Findings include: Review of facility policy entitled Leadership and Communication dated 4/1/25, indicated the facility will have a QAPI steering committee which included the following members Administrator, Director of Nursing, Infection Control, Medical Director . and Committee Members - Per CMS regulations . Review of the QAPI Committee Attendance Records for the October 2024 meeting revealed no evidence on the attendance sign-in for the required QAPI meeting that the Director of Nursing was in attendance. Review of the QAPI Committee Attendance Records for the February 2025 meeting revealed no evidence on the attendance sign-in sheets for the required QAPI meeting that the Infection Preventionist was in attendance. During an interview on 5/8/25, at 12:15 p.m. the Nursing Home Administrator (NHA) confirmed the facility lacked evidence that the Director of Nursing and the Infection Preventionist attended the Quarterly QAPI Committee meetings as required. He/she also confirmed that the Director of Nursing and the Infection Preventionist should be in attendance for the QAPI meetings as required. 28 Pa. Code 201.18(e)(1)(3) Management

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to properly safeguard and administer resident medications for one of six residents reviewed (Resident R1). Findings include: Review of facility policy dated 10/11/23, entitled Medication Administration indicated that All medications shall be given by the person who prepared the dose. Assure that the resident has enough fluids to swallow their medication. Never leave medication at the bedside. Be sure that all medication is administered and that no medication remnants remain in the cup. Observation of Resident R1's room on 10/01/24, at approximately 11:25 a.m. revealed a medication cup from the morning medication pass with two pills identified as Eliquis 2.5 mg (a blood thinner) and Celexa 10 mg (an antidepressant) sitting on the resident's bedside tray table. Resident R1 was sound asleep, and the Licensed Practical Nurse (LPN) Employee E1 who prepared the medication was at the nurse's station. During an interview on 10/01/24, at the time of the observation, Registered Nurse Employee E2 confirmed that Resident R1's medications should not have been left alone in the room for the resident and the administering LPN Employee E1 should have ensured Resident R1 took the mediations prior to leaving the room. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Setup, last reviewed 8/09/2023, indicated that the procedure of checking and documenting temperatures on the appropriate form was to occur at all meals. The policy and procedure also identified that the High Temp dish machine wash temperature ranges should be 150 degrees Fahrenheit (F) to 160 degrees F and that the final rinse temperatures should be at least 180 degrees F and up to 194 degrees F to ensure proper sanitization. Upon observation of the dish machine on 6/15/2024, at 3:30 p.m. it was confirmed that the dish machine was a hot water temperature machine. Review of the dish machine temperature logs revealed that for the month of May 2024, out of 93 temperatures documented there were 73 temperatures in the range of 160 -170 degrees F and all below the required 180 degrees F. For the month of June 2024, out of 42 temperatures documented there were 28 in the range of 160-170 degrees F and all below the required 180 degrees F. During an interview, on 6/15/24, at 3:35 p.m. it was confirmed by the Dietary Manager, that the documented temperatures as above did not meet the required 180 degrees F for the final rinse and that staff had not been properly trained on recording dish machine temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide the necessary assistance to maintain grooming and personal hygiene for five of 19 residents (Residents R2, R5, R15, R16, and R22). Findings include: A facility policy entitled, A.M. Care (Morning Care), dated 8/09/23, indicated that the purpose of a.m. care was to: refresh the resident; provide cleanliness, comfort, and neatness; prepare the resident for breakfast; assess the resident's condition; assess the resident's needs; and promote psychosocial well-being. Resident R15's clinical record revealed an admitted [DATE], with diagnoses including stroke affecting his/her left side, lack of coordination, urinary incontinence, blindness, and dementia. A care plan entitled self-care deficit indicated that he/she required extensive assistance (resident involved, staff provide weight bearing support) of two staff members for grooming, hygiene, and dressing. Observation on 6/15/24, at 1:10 p.m. revealed Resident R15 sitting in the hallway in his/her wheelchair, dressed in street clothes, and disclosed to the surveyor that he/she had not been cleaned up yet, thought that he/she should be cleaned up before lunch, and that it was not his/her scheduled shower day. Resident R22's clinical record revealed an admitted [DATE], with diagnoses including psychotic disorder, mild intellectual disabilities, limitations of activities due to disabilities, and muscle wasting. A care plan entitled person-centered care indicated that he/she required extensive assistance of one staff for grooming, hygiene, and limited assistance of one staff for dressing. Observation on 6/15/24, at 1:17 p.m. revealed Resident R22 sitting in his/her wheelchair in their room and disclosed to the surveyor that he/she had not been washed up yet, and that it was not his/her scheduled shower day. Resident R5's clinical record revealed an admitted [DATE], with diagnoses including traumatic brain injury, abnormal posture, mild intellectual disabilities, limitations of activities due to disabilities, and muscle wasting. A care plan entitled person-centered care indicated that he/she required supervision of one staff for dressing and extensive assistance of one staff for grooming and hygiene. Observation on 6/15/24, at 1:21 p.m. revealed Resident R5 sitting in his/her wheelchair dressed in street clothes and disclosed to the surveyor that he/she had not had his/her a.m. care completed. Resident R2's clinical record revealed an admitted [DATE], with diagnoses including multiple sclerosis (damages the protective cover around nerves in the brain, spinal cord, and optic nerves and causes muscle weakness, vision changes, numbness, and memory issues), a care plan entitled person-centered care indicated that he/she required extensive assistance of one-two staff for grooming, and hygiene. Observation on 6/15/24, at 1:32 p.m. revealed Resident R2 lying in bed with his/her soiled shirt pulled up and disclosed to the surveyor that he/she had not been cleaned up yet and liked it to be done before breakfast. Resident R16's clinical record revealed an admitted [DATE], with diagnoses including broken right leg, muscle wasting, Schizophrenia (chronic brain disorder with symptoms that may include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation), Bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A care plan entitled indicated he/she required extensive assistance of one-two staff for grooming and hygiene. Observation on 6/15/24, at 1:40 p.m. revealed Resident R16 sitting in his/her wheelchair in their room and disclosed to the surveyor that he/she hasn't' been washed up yet and probably won't be until he/she gets undressed for bed. During an interview on 6/15/24, at 1:47 p.m. Nurse Aide Employee E2 confirmed that as far as he/she knew all residents on the hall had been cleaned up except for the independent residents. During an interview on 6/15/24, at 1:50 p.m. Licensed Practical Nurse Employee E1 confirmed that each resident should be cleaned up in the morning every day, and that all residents on that hall required at least an assist of one staff person with personal hygiene, grooming and dressing, and that no one on that hall was independent. During an interview on 6/16/24, at 12:36 p.m. the Director of Nursing confirmed all residents are to be freshened/cleaned up every day by 10:30 a.m. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns identified during resident council minutes for three of three months reviewed (March, April, and May 2024). Findings include: Review of the March 2024 Resident Council Meeting Minutes revealed: lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included using chewing tobacco in resident room, main dining room doors being locked, and staff call bell response times. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Grievance Concerns dated 3/27/24, revealed Resident Council concerns were documented and corrective actions included reviewing tobacco policy with resident, education provided about resident safety while dining room construction is completed, and reported to nursing staff and nurse aid supervisor to discuss and educate staff on call bell response times. Concern forms lacked evidence of resolutions of resident concerns. Review of the April 2024 Resident Council Meeting Minutes revealed: lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included a resident's dentures not fitting, continued delay in call bell response times, staff not available at nurse's station, smoke break times not consistent, dirty bathroom, resident not able to fully utilize his/her wheelchair, and missing clothing. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Grievance Concerns dated 4/25/24, revealed Resident Council concerns were documented and corrective actions included that someone spoke with housekeeping and educated resident to report to staff when the bathroom needed cleaned, consulted nursing staff about resident's dentures not fitting, educated nursing staff on call bell response times and initiate testing/observation of call bell responses, and educate resident and nursing staff about staff availability at nurse's station. Concern forms lacked evidence of resolutions of resident concerns. Review of the May 2024 Resident Council Meeting Minutes revealed: lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included rules for visiting peers of the opposite gender in their rooms, and missing clothing. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Grievance Concerns dated 5/29/24, revealed Resident Council concerns were documented and corrective actions included a search conducted by staff and laundry notified of missing clothing, resident educated that staff should be made aware of room visits and roommates need to concur and be respected, educated nursing staff on call bell response times and initiate testing/observation of call bell responses, and educate resident and nursing staff about staff availability at nurse's station. Concern forms lacked evidence of resolutions of resident concerns. During interviews on 6/16/24, between 10:30 a.m. and 11:30 a.m. Resident Council members (Residents R31, R77, R58, and R86) confirmed that previous concerns are not discussed at Resident Council Meetings, and they are not informed by the facility of how their concerns are being resolved. During an interview on 6/17/24, at 2:30 p.m. the Director of Nursing and Nursing Home Administrator confirmed that there was lack of evidence that the repeated education was effective, there was a lack of developing an alternative method of resolution to the repeated concerns, and there was a lack of evidence that the Resident Council was informed of the outcome and was satisfied with the outcomes by the facility. During an interview on 6/18/24, at 10:12 a.m. the Nursing Home Administrator and Registered Nurse Assessment Coordinator confirmed there is no evidence that previous concerns were discussed at Resident Council Meetings, and residents are not informed by the facility of how their concerns were resolved. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1)(4) Management

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each residents' physical, mental, and psychosocial needs. The facility failed to obtain physician orders for smoking for one of 19 residents reviewed (Resident R9). Findings include: Resident's R9's clinical record revealed an admitted [DATE], with diagnoses of multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves), heart problems, anxiety, and bipolar (disorder with mood swings ranging from depressive lows to manic highs). Review of a facility policy entitled, Tobacco and Vaping Policy, dated 8/09/23, indicated that the purpose to ensure that the facility meets Federal and State regulations and guidelines regarding smoking under the home's safety rules and under applicable Federal and State laws and rules unless not medically advisable as documented in the resident's medical record by the attending physician or unless contradictory to written admission policies. Review of Resident R9's clinical record lacked evidence a physician's order was obtained for smoking. Observations on 6/15/24, and 6/16/24, revealed Resident R9 smoking outside in a gathering area. During an interview on 6/18/24, at 11:50 a.m., the Director of Nursing (DON) confirmed that there was no physician's order for Resident R9 to be smoking. The DON further confirmed that a physician's order is necessary to ensure smoking is appropriate for Resident R9 to safely participate. 28 Pa. Code 209.3(a) Smoking 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to assure that medication regimens were free of potentially unnecessary medications for two of 19 residents reviewed (Residents R38 and R69). Findings include: A facility policy entitled Drug Regimen Review dated 8/09/23, indicated that: the facility shall maintain copies of completed pharmacy reports; that the prescriber/licensed designee shall act upon the Drug Regimen Review findings/recommendation in a timely manner of 21 days or less; and that the prescriber/licensed designee shall document on the drug regimen review form whether he/she disagrees with the recommendations, and provide a brief clinical rationale if no change is to be made. Resident R38's clinical record revealed an admitted ,d+[DATE], with diagnoses including alcohol abuse with alcoholic-induced psychotic disorder, dementia with behavioral disturbances, and stroke. Resident R38's clinical record contained a Physician's Communication Form dated 4/26/24. The clinical record lacked copies of additional completed pharmacy reports and physician communication forms since the last full health survey of 7/25/23. During an interview on 6/17/24, at 2:55 p.m. the Director of Nursing confirmed that the facility was only able to locate one Physician Communication Form from the pharmacy dated 4/26/24. Resident R69's clinical record revealed and admitted [DATE], with diagnoses including dementia with behavioral disturbance, anxiety, major depression with psychotic symptoms, and stroke. Resident R69's clinical record contained a Physician's Communication Form dated 1/31/24. The clinical record lacked copies of additional completed pharmacy reports and physician communication forms since the last full health survey of 7/25/23. During an interview on 6/18/24, at 8:43 a.m. the Director of Nursing (DON) confirmed that the facility was only able to locate one Physician Communication Form from the pharmacy for Resident R38 dated 4/26/24, and one form for Resident R69 dated 1/31/24. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of established guidelines from the American Heart Association (AHA) for cardiopulmonary resuscitation (CPR - emergency life-saving procedure that is done when the heart stops beating and when performed immediately can double or triple chances of survival after cardiac arrest), facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide CPR as required for one of one resident reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility did not administer CPR to Resident R1 as required. This failure placed 43 of 95 residents ( R2, R3, R4 R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21 R22, R23 R24 R25, R26, R27 R28, R29, R30, R31, R32 R33, R34, R35 R36, R37, R38 R39, R40, R41, R42, R43, and R44), that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of guidelines from the AHA, dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril (serious or immediate danger) to the rescuer. Review of facility policy entitled Cardiopulmonary Resuscitation Procedure CPR For The Adult Victim dated [DATE], indicates to: Check for response, tap the victim's shoulder and shout are you all right. If there is no response shout/summons help; assign someone to check the code status of the victim; if victim has orders for resuscitation delegate staff to call 911, get AED, announce code, obtain emergency cart, call physician, and call family; check for pulse - if no definite pulse, start chest compressions; open airway and give two breaths; and to continue until EMS arrives. Residents R2 through R44's clinical record review of physician's orders revealed that CPR be administered in the event that they became unresponsive with no pulse. Resident R1's clinical record revealed an admitted [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD - progressive lung disease resulting in shortness of breath), dysphagia (difficulty swallowing), and high blood pressure. A POLST (Pennsylvania Order for Life-Sustaining Treatment) dated [DATE], stated, FIRST follow these orders, THEN contact physician, certified registered nurse practitioner, or physician assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the physician and Resident R1 and Section A revealed that CPR/attempt resuscitation was to occur when no pulse and no breathing were present. Physician's Order dated [DATE], identified Resident R1 as a FULL CODE (allows for all interventions needed to restore breathing or heart functioning). Care plan initiated on [DATE], indicated Resident R1 is a FULL CODE and will receive CPR in the event of cardiac and/or respiratory arrest. Progress note completed by Registered Nurse (RN) Employee E1 dated [DATE], at 3:42 a.m. indicated that Resident sends roommate down to nurses station stating she can't breathe, resident won't keep oxygen on, educated that she needs to keep oxygen face mask up on her face covering her nose and mouth, moaning, lungs with a few rales / diminished in bases. Resident can talk in complete sentences with no distress noted in speech. Reassurance that she is doing fine, continues to be nervous / anxious. Resident encouraged to close eyes and sleep, she is doing fine, she needs to relax. Progress note completed by RN Employee E1 dated [DATE], at 3:51 a.m. indicated that Resident on rounds noted to have ceased to breathe, resident cold and mottled with no heart rate or breathing noted, pronounced at 0351. Progress note completed by Licensed Practical Nurse (LPN) Employee E2 dated [DATE] at 4:00 a.m. indicated that During rounds, CNA reported that resident was not breathing, RN Supervisor notified for assessment. Mottling present with absence of breath sounds or pulse. Progress note completed by RN Employee E1 dated [DATE], at 4:10 a.m. indicated that Husband was notified that resident had ceased to breath Progress note completed by RN Employee E1 dated [DATE], at 7:16 a.m. indicated (name mentioned) CRNP (Certified Registered Nurse Practitioner) notified of resident CTB at 0351. During interview on [DATE], at 9:20 a.m. Director of Nursing (DON) provided the following information: RN Employee E1 was working the night Resident R1 passed way. RN Employee E1 did call the DON to inform her of Resident R1 passing away and informed the DON that he/she did not provide CPR as ordered as he/she felt Resident R1 had been gone for a while and it would have been abuse of a corpse. DON was not in the facility at the time and was unable to assess Resident R1 herself having to go solely on what RN Employee E1 reported to her via telephone. During a telephone interview on [DATE], at 9:27 a.m. RN Employee E1, provided the following information: Certified Nurse Aides (CNA) completed rounds around 2:00 a.m. to 2:30 a.m. and there was no indication of any changes with Resident R1. Around 3:51 a.m. RN Employee E1 was starting to do his/her routine rounds, when the CNA's informed him/her that they thought Resident R1 was gone. RN Employee E1 went to assess Resident R1 and found him/her to be in bed with eyes open, and pupils fixed and dilated, mouth open, cool to touch, mottled (red or purple blotches or streaks caused by lowered blood flow to the skin) to his/her upper chest, and with no respirations or heart rate. RN Employee E1 stated he/she attempted to call the physician, but it was not going through, and he/she notified the CRNP at 7:15 a.m. RN Employee E1 stated he/she notified Resident R1's husband at 4:15 a.m. and the husband did ask if Resident R1 was revivable, and he/she informed the husband that Resident R1 was not. RN Employee E1 stated that he/she did not perform CPR as Resident R1 wished, as he/she felt Resident R1 had been gone for a while and it would have been abuse of a corpse. During interview on [DATE], at 10:45 a.m. Nursing Home Administrator (NHA) and DON provided the following information: Licensed Practical Nurse (LPN) Employee E2 was outside on break at the time of the incident and did not see Resident R1. LPN Employee E2 did complete a progress note based on what he/she was told by staff who were present. During a telephone interview on [DATE], at 12:28 p.m. CNA Employee E3 provided the following information: Resident R1 was last checked on between 1:30 a.m. and 2:00 a.m. At that time, he/she was in bed with his/her oxygen on and was responding to staff. At 3:40 a.m. CNA Employee E3 went into Resident R1's room and found him/her with dried blood all over his/her face and arm was cold. CNA Employee E3 left Resident R1's room and tried to call LPN Employee E2 who was on break. LPN Employee E2 did not pick up her phone, so CNA Employee E3 found RN Employee E1 and told him/her who then went to Resident R1's room. The facility failed to promptly initiate CPR in accordance with the resident's wishes and professional standards of nursing to a resident who had requested CPR upon admission, had a physician's order for CPR and had been identified as a FULL CODE, when finding the resident unresponsive, without a pulse or breathing and without clear clinical signs of death placing 43 other residents who had requested that CPR be administered in the event that they were to suddenly become unresponsive and pulseless in Immediate Jeopardy. The NHA was notified of the Immediate Jeopardy (IJ) situation and IJ template was provided to the NHA on [DATE], at 12:21 p.m. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA, DON, and Corporate Quality Assurance (QA) Director on [DATE], at 2:13 p.m. which was accepted at 2:32 p.m. The plan include: The facility Corporate QA RN reviewed the facilities CPR policy and worked with the facility Administrator and DON to develop the facilities IJ Abatement plan. All facility Licensed nurses will be immediately re-educated on the facilities CPR policy and Emergency procedures policy. The Emergency procedures policy was reviewed and revised to clearly guide the facility license nursing staff on emergency measures including CPR. The education was started [DATE] and will be completed today. If the nurses are not working today and have not yet been re-educated on the policies they will be reached via phone and re-educated. The licensed nurses will not be allowed to work until re-education completed. This education will be done by the facility Clinical Director RN and the facility RN Staff Developer. The facility nurse infection preventionist will also review all current resident's advanced directive / POLST forms to be sure that current advance directive / code status orders are currently and clearly noted on the medical record and that the resident care plan clearly reflects the residents current code status. These reviews have started and will be completed today. The facility contacted the facility Medical Director and as part of the facilities QAPI committee reviewed with the Medical Director the facilities action plan to address the IJ at F678. The facility will continue to monitor through daily reviews of clinical record / EHR to ensure the facility CPR policy is followed and CPR is provided per policy if a resident is a full code. The facility will ensure that all new nursing staff to the facility have the CPR policy reviewed as part of their orientation before providing resident care. This will be monitored by the facility DON, and Clinical Director. The facility CPR policy will be part of their orientation paperwork. On [DATE], during an onsite visit, the Immediate Jeopardy was lifted at 12:53 p.m. after ensuring the Immediate Action Plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(3)(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that professional licensed staff implemented life-saving interventions regarding residents requiring cardiopulmonary resuscitation (CPR - emergency life-saving procedure that is done when the heart stops beating and when performed immediately can double or triple chances of survival after cardiac arrest) as required by the facility. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to direct the overall operation of the facility's activities in accordance with current Federal, State, and local laws and regulations, guidelines and standards, as directed by Company policy. The NHA also has duties and responsibilities to develop systems and standards for the delivery of health care services and is accountable for assuring the delivery of high-quality care, including adherence to professional standards of care in accordance with State, Local, and Federal regulations. Review of the job description for the DON revealed that the DON's purpose is to organize, develop, and direct nursing services and to maintain standards of good nursing practice. The DON also has duties and responsibilities to organize, develop, and direct nursing administration and patient care. Develops and maintains nursing service objectives and standards of nursing practice. Develops and maintains nursing objectives for the institution. Ensures nursing policies and procedures are followed. Based on the findings that the facility failed to ensure that professional licensed staff implemented life-saving interventions regarding residents requiring CPR, the NHA and the DON failed to fulfill their purpose and essential job duties to ensure that the Federal and State guidelines and regulations were followed. Refer to F678 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to follow physician's orders for laboratory work for one of five residents reviewed (Resident R45). Findings include: Review of facility policy entitled RN Supervisor Guide dated 8/9/23, indicated that laboratory orders are entered into PCC (Point Click Care) and that staff is to write down the physician initials, order date, and labs in the RN Lab Book. Review of Resident R45's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (difficulty swallowing), atrial flutter (abnormal heart rhythm causing your heart to beat too fast), and kidney failure. Review of Resident R45's clinical record revealed a physician's order dated 2/19/24, at 13:17 for a CBC (complete blood count), Iron, and Ferritin level one time only for anemia. Further review of Resident R45's clinical record revealed that the laboratory work that was collected and completed on 2/20/24, lacked evidence of the Iron and Ferritin level being completed as ordered. During an interview on 3/6/24, at 12:12 p.m. the Director of Nursing confirmed that the clinical record lacked evidence of the Iron and Ferritin levels being drawn per physician's orders for Resident R45. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of closed clinical records and staff interview, it was determined the facility failed to include a discharge summary for one of three closed records (Closed record CR91). Findings include: Nursing notes dated [DATE], revealed that Resident CR91 was discharged out to the hospital on [DATE]. During an interview on [DATE], at 1:00 p.m. the Social Worker verified that the Resident CR91 expired after discharge from the facility. Review of closed clinical records revealed that Resident CR91's record lacked a discharge summary. During an interview on [DATE], Registered Nurse Employee E5 at [DATE] 10:39 a.m., verified that the Resident CR91's clinical record did not contain a discharge summary. 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE]