Every finding on record at LECOM At Village Square, Llc

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for five of 20 residents reviewed (Residents R1, R4, R14, R43 and R100).Findings include: Review of facility policy entitled Transfer or Discharge, Facility-Initiated dated 10/1/25, indicated Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: The basis for the transfer., Contact information., Resident representative information., Advance directive information., All special instructions or precautions., Comprehensive care plan goals., All other information necessary to meet the residents' needs. Resident R1's clinical record revealed an admission date of 9/18/25, with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and hypertension (high blood pressure). Resident R1's progress notes revealed notes dated 11/7/25 and 10/14/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R4's clinical record revealed an admission date of 3/18/25, with diagnoses that included hypertension, dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Resident R4's progress notes revealed notes dated 7/22/25, and 8/3/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R14's clinical record revealed an admission date of 4/9/24, with diagnoses that included diabetes, atrial fibrillation (A-Fib - irregular and often rapid heartbeat), and chronic respiratory failure. Resident R14's progress notes revealed notes dated 5/11/25, 6/6/25, 6/12/25, 6/27/25, 8/18/25, 10/4/25, 11/15/25, and 12/4/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R43's clinical record revealed an admission date of 9/19/24, with diagnoses that included hypertension, anxiety, and depression. Resident R43's progress notes revealed notes dated 11/16/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R100's clinical record revealed an admission date of 9/16/25, with diagnoses that included atrial fibrillation, diabetes, and repeated falls. Resident R100's progress notes revealed a note dated 11/17/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 12/17/25, at 12:10 p.m. the Director of Nursing confirmed that Residents R1, R4, R14, R43 and R100s clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

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 20 residents reviewed (Resident R11).Findings include: Review of facility policy entitled Care Plans, Comprehensive Person Centered dated 10/1/25, indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R11's clinical record revealed an admission date of 9/19/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R11's progress notes revealed a note dated 11/21/25, at 6:56 p.m. indicating that his/her urinary catheter was removed. Review of Resident R11's Care Plan for altered genitourinary status dated 9/19/25, revealed interventions to change urinary catheter monthly, change urinary drainage bag, cover urinary drainage bag, flush urinary catheter, and provide urinary catheter care. Review of Resident R11's November 2025, treatment record revealed that his/her urinary catheter was discontinued on 11/22/25. Review of Resident R11's current physician orders revealed no current order for a urinary catheter. During an interview on 12/17/25, at 12:10 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that Resident R11's altered genitourinary status care plan was not reviewed/revised to reflect current resident care and services and also confirmed that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(ix) Medical records28 Pa. Code 211.10(c)(d) Resident care policies

Based on review of facility policy, manufacturer's guidelines, observations, and staff interview, it was determined that the facility failed to ensure an expired medication was discarded in a timely manner in one of two medication carts reviewed (East Wing Cart). Findings include: Review of a facility policy entitled Medication Labeling and Storage dated [DATE], revealed that, multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observation on [DATE], at 3:22 p.m. of the East Wing medication cart revealed an open injector pen of Humalog insulin with an open date of [DATE], therefore the medication was expired. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the injector pen of Humalog insulin was expired and should have been discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 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 documents and resident and staff interviews, it was determined that the facility failed to meet the needs of residents in a timely manner for nine of 11 residents interviewed (Residents R1, R4 through R9, R11 and R12). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m. during random resident interviews, the following residents complained of poor call bell response time: Resident R1 expressed frustration related to that often after activating the call bell for assistance, the staff would not respond for an hour or longer. Resident R4 indicated that they were worried that in the event of an emergency staff would not respond and often wait for response to their call light for over an hour. Resident R5 stated that staff would not respond to call bells, and were frequently observed ignoring the call lights while looking at their cell phones. Residents R6 and R7 also complained that call bell response was extremely slow and they often had to up to an hour or longer for assistance. Resident R9 indicated that he/she often waited up to 45 minutes for staff to answer the call bell, only to be told that they would be back but no one would return. Residents R10 and R11 complained of over an hour wait on many occasions before any staff responded to the call light activation. A review of the Resident Council meeting concerns for the March 25, 2025, meeting documented many concerns of call bells not being answered timely. During interview on 3/29/25, at approximately 11:00 a.m. the Nursing Home Administrator confirmed that long call bell response times were not appropriate and that the facility was aware of the concerns. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of facility documents and resident and staff interviews, it was determined that the facility failed to serve food that was at a palatable temperature for nine of 11 residents interviewed (Residents R1, R4 through R9, and R11). Findings include: During a tour of the facility on 3/29/25, from 8:20 a.m. through 10:00 a.m., during random resident interviews, the following alert and oriented residents complained of consistently of receiving cold food. Residents R1, R4 through R9, and R11 all expressed frustration that their meals were not palatable because the food was usually cold when delivered by staff, partly due to the trays sitting in the hall for long periods of time until they are delivered. A review of Resident Council meeting concerns for January 2025, February 2025, and March 2025, documented multiple resident complaints of being served cold food. During an interview on 3/29/25, at approximately 11:00 a.m. the Nursing Home Administrator confirmed awareness of the issue of facility food being served cold to the residents. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies and documentation and clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed regarding transfers (Resident R72) was free of neglect during care which resulted in actual harm of an anterior dislocation of left shoulder (when the shoulder slides forward out of the socket). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Abuse and Neglect Definitions dated 10/14/24, indicated Neglect: The failure to provide the goods and services necessary to avoid physical harm . Review of facility policy entitled Abuse and Neglect dated 10/14/24, indicated It is the policy .to have zero tolerance for incidents of abuse and/or neglect. Review of facility policy entitled Safe Lifting and Movement of Residents dated 10/14/24, revealed that Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of facility policy entitled Lifting Machine, Using a Mechanical dated 10/14/24, revealed that At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift [machine used to lift someone and transport from one location to another]. Review of Resident R72's clinical record revealed an admitted [DATE], with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically), Diabetes (a health condition caused by the body's inability to produce enough insulin), and Cognitive Communication Deficit (a condition that makes it difficult to communicate due to memory issues). Review of Resident R72's Quarterly Functional Abilities and Goals Assessment (an assessment tool used to facilitate the management of care) dated 11/7/24, revealed that Resident R72 required dependent assistance for transfer from chair to bed, bed to chair. The Functional Abilities and Goals Assessment defined dependent as Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity Review of Resident R72's Kardex (an easy to read document of resident care needs for the nursing assistants (NA) to reference), revealed under transferring mechanical lift and assist X 2 [times two staff]. Review of Resident R72's Tasks (a place that the nursing assistants document their care for the resident), revealed under Mechanical lift and assist times two, Transfer support provided. Documentation marked was for two plus person's physical assist. Review of Resident R72's care plan with a focus of Has an ADL [Activities of Daily Living] self-care performance deficit with an initiated date of 8/5/24, revealed under interventions Transfer: mechanical lift and assist X 2. Review of Resident R72's clinical record revealed a nurse's note dated 11/7/24, that the nurse was informed that Resident R72 sustained an injury to his/her left shoulder during transfer from wheelchair to bed with the stand-up lift [a type of mechanical lift to assist with transfers]. Resident felt like he/she was slipping and grabbed ahold of left lift bar and did not let go. Resident R72 complained of pain to his/her left shoulder with movement and touch. Resident R72's left shoulder also had dimpling (a symptom that makes the skin look bumpy or textured like an orange peel). Notification was made to the physician and the physician ordered to send Resident R72 to the emergency room . Review of Resident R72's emergency room visit records dated 11/7/24, revealed a diagnosis of anterior dislocation of left shoulder. Review of information submitted by facility dated 11/8/24, revealed that Resident R72 was transferred to the hospital and returned with a diagnosis of an anterior dislocation of left shoulder. Review of the facility's investigation revealed that on 11/7/24, NA Employee E10 was transferring Resident R72 with a sit-to-stand lift without two staff members as required. NA Employee E10's statement revealed he/she was getting Resident R72 up with the sit-to-stand trying to put Resident R72 to bed to go to sleep. Resident R72's knees gave in on the lift and Resident R72 started sliding down slowly, NA Employee E10 then requested his/her fell ow teammate for help. NA Employee E10 stated that Resident R72 complained that his/her arms were hurting. An addendum on 11/8/24, on NA Employee E10's statement by the Director of Nursing (DON) revealed that NA Employee E10 was lifting Resident R72 without a second staff member present at the start of using the sit-to-stand lift. Review of documentation submitted by the facility dated 11/8/24, revealed that the facility initiated an investigation, regarding resident neglect on 11/7/24. The investigation revealed NA Employee E10 was suspended pending investigation. Interview with Physical Therapist (PT) Employee E9 on 11/19/24, at 10:15 a.m. revealed that Resident R72's therapy ended on 9/11/24, and upon Resident R72's therapy ending, his/her discharge transfer status was a mechanical lift with assist of two staff. PT Employee E9 also revealed that upon therapy ending Resident R72's special instructions in his/her clinical record were updated by therapy to a mechanical lift with assist of two staff. Interview with the Nursing Home Administrator on 11/19/24, at 10:30 a.m. confirmed that NA Employee E10 did not get another staff member to assist in the transfer of a resident that required transfers of two staff. Interview also revealed that NA Employee E10 had not worked in the facility since the incident on 11/7/24. The facility failed to ensure that Resident R72 was free from neglect resulting in actual harm of an anterior dislocation of left shoulder from a transfer with assistance of one staff that required assistance of two staff. This deficiency is cited as past non-compliance. On 11/8/24, the facility initiated a plan of correction that included the following: On 11/8/24, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers were performed per facility policy and resident care plans. Immediate suspension of NA Employee E10. Immediate education regarding resident mechanical lifts and checking transfer status before transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's, which occurred 11/8/24, and was ongoing. Therapy Department conducted competencies of staff included in the education to ensure that they understood the education and could perform the task correctly. Competencies were reviewed during this onsite investigation. Interviews with LPN Employees E3 and E4, NA Employees E5, E6 and E7, and RN Employee E8 confirmed the facility initiated education and competencies starting 11/8/24, which included education on where to find transfer status for the resident and performing a return demonstration to ensure proper knowledge and technique while using mechanical lifts. Audits were conducted to ensure safe transfers for residents which occurred on 11/8/24, through 11/18/24, and remain ongoing. During an interview with the Nursing Home Administrator (NHA), these audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting post incident. The NHA also identified that review of resident transfers will continue to be reviewed at QAPI meeting and will continue until determined otherwise by the QAPI committee. The facility has demonstrated compliance with using correct transfer status for residents since 11/14/24. During an interview with the NHA on 11/19/2024, at 10:30 a.m. and review of the facility's immediate actions, education, competencies, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding transfer status of residents and had achieved substantial compliance. 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(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and 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 four of 19 residents reviewed (Residents R71, R49, R28, and R7) and failed to ensure that a baseline care plan for an indwelling foley catheter (a medical device that helps drain urine from the bladder) was developed and implemented for one of 19 residents reviewed (Resident R178 ). Findings include: A facility policy entitled, Care Plans - Baseline dated 10/14/24, revealed The baseline care plan included instructions needed to provide effective, person-centered care of the resident to meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident .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: a. The stated goals and objective of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R71's clinical record revealed an admitted [DATE], with diagnoses that included dementia (memory/thinking problems that interfere with daily life and activities), dysphagia (difficulty swallowing), and malignant neoplasm of the bronchus or lung (lung cancer). Resident R71's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R71 and/or his/her representative. Resident R49's clinical record revealed an admitted [DATE], with diagnoses that included muscle wasting and atrophy, dementia and hyperlipidemia (high cholesterol). Resident R49's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R49 and/or his/her representative. Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included dementia and heart failure (a condition where the heart cannot supply the body with enough blood). Resident R28's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R28 and/or his/her representative. Resident R7's clinical record revealed an initial admitted [DATE], with diagnoses that included hyperlipidemia, hypertension (high blood pressure), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Resident R7's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R7 and/or his/her representative. Resident R178's clinical record revealed an admitted [DATE], with diagnoses that included benign prostatic hyperplasia (enlarged prostate gland), heart failure, and dysphagia (difficulty swallowing). Resident R178's admission documentation revealed an indwelling foley catheter was present upon his/her entry into the facility. Resident R178's clinical record lacked evidence that a baseline care plan was developed for an indwelling foley catheter. During an interview on 11/18/24, at 12:15 p.m. Charge Nurse Employee E3 confirmed that a baseline care plan for an indwelling foley catheter had not been developed for Resident R178. During an interview on 11/18/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the clinical record for Residents R71, R49, R28, and R7 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within 24 hours of transfer for two of 19 residents reviewed (Residents R41 and R7). Findings include: Review of facility policy entitled, Admission, Transfer, and Discharge Rights dated 10/14/24, revealed, In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with a written notification within 24 hours of the transfer. Review of Resident R41's clinical record revealed an initial admitted [DATE], with diagnoses that included intellectual disabilities (certain limitations in cognitive functioning), dysphagia (difficulty swallowing), and hypertension (high blood pressure). A progress note dated 6/27/24, revealed that Resident R41 was transferred to the hospital. The clinical record lacked documentation indicating that Resident R41 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R7's clinical record revealed an initial admitted [DATE], with diagnoses that included hyperlipidemia (high cholesterol), hypertension, and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Progress notes dated 5/11/24, and 6/12/24, revealed that Resident R7 was transferred to the hospital. The clinical record lacked documentation indicating that Resident R7 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 11/18/24, at approximately 2:20 p.m. the Corporate Nursing Home Administrator confirmed that the clinical records lacked evidence that Residents R41 and R7 and/or their representative were provided with a copy of the facility bed-hold policy within 24 hours of transfer or upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(f) Resident rights

Based on review of facility policy and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (two east medication cart) and one of two medication rooms reviewed (first floor medication room). Findings include: Review of a facility policy entitled Expiration and Disposal of Medication dated [DATE], revealed Refrigerated items will be received from pharmacy with date opened sticker, nursing to write appropriate date once item is opened and/or removed from fridge. Nursing staff will inventory medications to assure medications are discarded when expired. And Guidelines: Medication Insulin Expiration after opening 28 days Medication PPD/TB [solution to test for tuberculosis] Expiration after opening 30 days. Review of manufacturer's guidelines revealed that an open pen of Aspart Insulin (medication to treat diabetes) must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open pen of Glargine Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Tubersol (solution used to test for tuberculosis) should be discarded within 30 days after opening. Observation of drug storage on [DATE], at 3:05 p.m. of the first floor medication room refrigerator revealed two open multi dose vials of Tubersol with no date indicating when the vials were opened. Observation of drug storage on [DATE], at 3:30 p.m. of two east medication cart revealed an opened Glargine Insulin pen with an open date of [DATE], and an expiration date of [DATE], an opened Aspart Insulin pen with an open date of [DATE], and an expiration date of [DATE]. Further observation revealed an open bottle of cholestacare tablets (a supplement), with a best by date of [DATE]. During an interview on [DATE], at 3:05 p.m. with Registered Nurse (RN) Employee E2, he/she confirmed that the opened Tubersol vials lacked open dates and staff were unable to determine the discard date. He/she also confirmed that the vials of Tubersol should have been discarded. During an interview on [DATE], at 3:30 p.m. the Director of Nursing confirmed that the Glargine Insulin pen, Aspart Insulin pen, and the bottle of cholestacare tablets were expired. He/she also confirmed that the Insulin pens and the bottle of cholestacare tablets 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 provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for two of six residents reviewed regarding psychotropic medications (Residents R12 and R67). Findings include: A facility policy entitled Antipsychotic Medication Use dated 10/14/24, revealed The need to continue PRN orders of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), heart failure, and chronic pain. A physician's order dated 6/3/24, identified to administer Vistaril (anti-anxiety medication) 50 milligrams (mg) by mouth every 24 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale with a duration for continued use beyond 14 days. Review of the October 2024 and November 2024 Medication Administration Records (MAR) for Resident R12 revealed that the PRN Vistaril was used on 10/1/24, 10/2/24, 10/3/24, 10/5/24, 10/6/24, 10/7/24, 10/9/24, 10/10/24, 10/12/24, 10/13/24, 10/15/24, 10/18/24, 10/19/24, 10/21/24, 10/22/24, 10/23/24, 10/25/24, 10/26/24, 10/27/24, 10/29/24, 11/2/24, 11/3/24, 11/5/24, 11/6/24, 11/11/24, 11/12/24, and 11/16/24. The October 2024 MAR, November 2024 MAR, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Vistaril for the 20 administrations in October 2024 and seven administrations in November 2024. Resident R67's clinical record revealed an admitted [DATE], with diagnoses that included anxiety and dementia (a disease that affects short term memory and the ability to think logically). A physician's order dated 12/8/23, identified to administer Vistaril 10 mg by mouth every 12 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale with a duration for continued use beyond 14 days. Review of the October 2024 and November 2024 MARs for Resident R67 revealed that the PRN Vistaril was used on 10/1/24, 10/2/14, 10/3/24, 10/7/24, 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/15/24, 10/16/24, 10/17/24, 10/19/24, 10/20/24, 10/21/24, 10/24/24, 10/27/24, 10/28/24, 10/29/24, 10/30/24, 11/2/24, 11/3/24, 11/4/24, 11/5/24, 11/6/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, and 11/16/24. The October 2024 MAR, November 2024 MAR, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Vistaril for 19 administrations in October 2024 and 14 administrations in November 2024. During an interview on 11/18/24, at 1:20 p.m. the Director of Nursing confirmed that Resident R12's and R67's Vistaril orders lacked the required stop date within 14 days or a clinical rationale with a duration for continued use beyond 14 days and that R12's and R67's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering the Vistaril. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure adequate physician orders were in place for an indwelling urinary catheter (a medical device that helps drain urine from the bladder) for one resident reviewed for catheters (R178). Findings include: Resident R178's clinical record revealed an admitted [DATE], with diagnoses that included benign prostatic hyperplasia (enlarged prostate gland), heart failure, and dysphagia (difficulty swallowing). Resident R178's admission documentation revealed an indwelling foley catheter was present upon his/her entry into the facility. Review of R178's order summary lacked evidence of that physician orders were in place for a urinary catheter, which would include but not limited to foley catheter and balloon size, foley catheter scheduled changes, foley catheter as needed changes due to soiling or dislodgement, draining the foley catheter collection bag, foley catheter collection bag changes, and foley catheter hygiene care. During an interview on 11/18/24, at 12:15 p.m. Charge Nurse Employee E3 confirmed that physician orders were not in place regarding the overall care for an indwelling foley catheter for Resident R178. 28 Pa. Code 201.14(a) Responsibility of licensee 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 transcribe a physician's order for an anxiety medication for one of 19 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication and Treatment Orders dated 10/14/24, indicated Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnosis that include Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), Diabetes (a health condition that caused by the body's inability to produce enough insulin), and Hypertension (high blood pressure). Review of Resident R1's clinical record revealed a physician's progress note dated 11/12/24, that indicated to add Hydroxyzine (an antianxiety medication) 25 milligrams (mg) every six hours as needed for anxiety. Further review of Resident R1's clinical record revealed his/her physician's orders lacked evidence that Hydroxyzine 25 mg every six hours as needed for anxiety was transcribed in his/her physician's orders. During an interview on 11/18/24, at 1:15 p.m. the Director of Nursing confirmed that the physician had ordered Hydroxyzine 25 mg every six hours as needed and the order was not transcribed on the physician's orders. He/she also confirmed that the Hydroxyzine order should have been transcribed on Resident R1's physician orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the manufacturer guidelines for the Modular Crescent Cuber (ice machine), dated 10/10/17, stated Be sure there is sufficient extra water supply line and drain line for the appliance to be pulled out for service. Separate piping to approved drain. Leave a 2-inch (5 cm) vertical air gap between the end of each pipe and the drain. Observations in the kitchen on 12/04/23, at approximately 11:15 a.m. revealed the ice machine drainage pipe resting on the floor drain and lacked a two-inch vertical air gap between the end of the pipe and drain. The drain and surrounding floor were observed unclean and black in color. Interview with the Dietary Manager on 12/04/23, at approximately 11:15 a.m. confirmed the ice machine's drainage pipe and floor drain lacked a two-inch air gap allowing the pipe to rest on the unclean drain creating unsafe storage for ice. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain resident dignity during medication administration for one of 18 residents reviewed (Resident R49). Findings include: Review of facility policy entitled Resident Rights with a policy review date of 11/7/2023, revealed, the resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care for the necessary personal and social needs. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness), depression, and anxiety. Observation of Resident R49 on 12/5/23, at 9:20 a.m. during medication administration revealed that he/she was administered insulin subcutaneously (SQ-Injection between the skin and muscle tissue) in the abdomen which required Resident R49's abdomen to be exposed. During the observation, prior to administration of the insulin, Licensed Practical Nurse (LPN) Employee E1 did not preserve resident dignity by closing the door to the room to prevent observations from passers by in the common area corridor and did not pull the privacy curtain between resident and their roommate in the room. During an interview with LPN Employee E1 on 12/5/23, at 9:22 a.m. it was confirmed that resident dignity was not maintained for Resident R49 during medication administration. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined the facility failed to implement part or all of the Antibiotic Stewardship Program for one of 18 residents reviewed (Resident R39). Findings include: Review of facility policy entitled Antibiotic Stewardship dated 11/07/23, revealed Antimicrobial prescribing protocols: assessment tools and management algorithms derived for and evidenced based clinical guidelines that are intended to be used as a resource for diagnosis and treatment of infections. Antimicrobial stewardship interventions and efforts to improve antimicrobial use will be regularly and will be implemented by a clinical leader. Review of Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included malignant neoplasm of prostate (a disease in which cancer cells form in the tissue of the prostate), secondary malignant neoplasm of bone (a disease in which cancer has started in another part of the body and has spread to the bone via the bloodstream or lymph nodes), obstructive reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), and urinary tract infection (UTI). Review of Resident R39's Indwelling Catheter care plan dated 9/21/23, revealed interventions to monitor/record/report to MD (doctor) for s/sx (signs/symptoms) UTI: pain, burning, blood tinged cloudiness, no output, deepening of urine color, increased pulse increased urinary frequency, foul smelling urine, fever, chills altered mental status behavior, change in eating patterns. Review of Resident R39's clinical record revealed nursing progress notes dated 11/30/23, Urine specimen collected as per, clear yellow urine noted, no sedimentation, denies any burning. Further nursing progress notes dated 12/04/23, revealed Informed in morning report that resident had UA C&S [culture and sensitivity lab test for infection] sent on 11/30/23 d/t [due to] family request. Resident has no urinary c/o [complaints] as of 12/4/23. Results sent to Dr.and VORB [verbal order read back] was given for Cipro [antibiotic] 500 mg [milligrams] PO [by mouth] BID [twice a day]. Daughter notified via phone call. Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact, and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severly impaired. During an interview on 12/06/23, at 10:15 a.m., Resident R39 (BIMS of 15) indicated he/she was unaware that an antibiotic was prescribed for a urinary tract infection. Resident R39 further indicated he/she was not assessed by nursing staff related to an infection. During an interview on 12/07/23, at 10:40 a.m. the Director of Nursing confirmed Resident R39's antibiotic was ordered related to a family request for a UA C&S, and Resident R39's clinical record lacked evidence that the facility utilized an infection assessment tool/Antibiotic Stewardship protocol for assessment of an infection. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record and facility policy, observation, and staff interview, it was determined that the facility failed to follow a physician's order for the administration of insulin for one of 18 residents reviewed (Resident R49). Findings include: Review of a facility policy entitled Medication Dispensed According to Prescribers Orders with a policy review date of 11/7/2023, revealed Verbal, written, and/or electronic orders are dispensed according to the prescriber's orders and are tailored to the resident's needs. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 diabetes (a condition that affects the way the body processes blood sugar), angina pectoris (chest pain), Neurocognitive disorder with behavioral disturbance (decreased mental function due to a medical disease other than psychiatric illness),depression, and anxiety. Review of Resident R49's physician's orders revealed that there was an order for NovoLog (type of insulin) injection solution to inject subcutaneously (between the skin and muscle tissue) before meals and at bedtime. Review of the Medication Administration Record revealed that insulin was to be administered at 7:30 a.m. Observation of Resident R49 on 12/5/23, at 9:20 a.m. revealed that he/she was administered insulin subcutaneously after finishing breakfast. During an interview on 12/5/23, at 9:22 a.m. Licensed Practical Nurse Employee E1 confirmed that Resident R49's NovoLog insulin should have been administered prior to eating meals and was administered after Resident R49 finished breakfast at 9:20 a.m. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of 18 residents reviewed (Residents R172 and R173). Findings include: Review of a facility policy entitled, 24/48 Hour Care Conference dated 11/07/23, indicated that a care conference was to be completed within 24-48 business hours to discuss short- and long-term goals, dietary concerns, physical limitations, interests and hobbies, medical diagnoses, physical therapy goals/concerns, billing, and care plan preferences. Review of Resident R172's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), osteomyelitis (infection of the bone), amputation of right toes, inflammatory spondylopathy of the neck (inflammatory arthritis affecting the spine), and unstable angina (chest discomfort or pain caused by an insufficient flow of blood and oxygen to the heart). Review of Resident R172's clinical record revealed two developed care plans: Advanced Directives dated 12/05/23, (seven days after admission), and Nutrition dated 12/06/23, (eight days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative. Review of Resident R173's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, heart disease, heart failure, irregular heartbeat, high blood pressure, and Type 2 Diabetes. Review of Resident R173's clinical record revealed two developed care plans; Advanced Directives dated 12/05/23, (five days after admission), and Nutrition dated 12/06/23, (six days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative. During an interview on 12/06/23, at 11:40 a.m. the Director of Nursing and the Executive Director confirmed the 24-48-hour care conference was intended to present the resident and/or representative with the baseline care plan, there was no evidence that the baseline care plan was developed, and that the 24-48-hour baseline care plan summary had not been or provided to Residents R172 and R173 and their representatives. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on review of clinical records and resident care documentation, observations, and interviews with residents, it was determined that the facility failed to provide showers based on the resident's shower preferences and schedule due to lack of staff for five of 15 residents (Residents R4, R5, R9, R17, and R59) and failed to provide pressure ulcer prevention interventions for one of one residents due to lack of staff. (Resident R9). Findings include: Review of Resident R4's most recent Minimum Data Set (MDS-a periodic review of resident care needs) completed on 12/22/22, revealed in section G0120 that bathing self-performance and support provided activity itself did not occur. No evidence of shower/bath documentation was provided for Resident R4. An interview with Resident R4, with a Brief Interview for Mental Status score (BIMS) of 14/15, on 1/28/23 revealed he/she was washed up with a washcloth, but never bathed/showered. Review of R5's most recent MDS completed on 12/09/22, revealed in section G0120 that bathing self-performance and support provided activity itself did not occur. No evidence of shower/bath documentation was provided for Resident R5. An interview with Resident R5, with a BIMS of 13/15, on 1/28/23 indicated he/she never got a shower. He/she stated, What showers? and stated I know we are short staffed; we don't get showers/baths. Resident R5 was observed with greasy hair on 1/28/23 and 1/29/23. Review of Resident R9's most recent MDS completed on 1/06/23, revealed in section G0120 bathing self-performance as total dependence and support provided as two plus persons physical assist. In the past 30 day period, one day was acknowledged in documentation as shower provided for Resident R9. Resident R9, with a BIMS of 6/15, was observed in bed on 1/28/23, 1/29/23, and 1/30/23 with greasy hair. An interview with Licensed Practical Nurse (LPN) on 1/30/23, at 2:15 p.m. revealed that Resident R9 was not turned and repositioned on 1/30/23, throughout the day, related to not enough staff to get things done such as turning/repositoning and placing pressure ulcer prevention devices such as a pillow/wedge on Resident R9's bed to assist in turning and repositioning. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included schizophrenia (A disorder that affects a persons ability to think, feel, and behave clearly), muscle wasting and atrophy, morbid obesity, and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone). Review of Resident R17's most recent MDS completed on 12/22/22 revealed in section G0120 that bathing required physical help in part of bathing activity and one person physical assist. During an interview on 1/28/23, at 12:00 p.m. Resident R17 revealed that showers are supposed to be completed three days per week on Mondays, Wednesdays, and Fridays because he/she sweats a lot. Resident R17 does not get showers per the shower schedule and preference, and sometimes goes over one week without a shower. During the interview, Resident R17 stated, I am told that I can not get a shower because the staff is busy or they dont have enough staff to shower that day. Review of the facility shower schedule book, it was revealed that Resident R17 is scheduled to get showers on Monday, Wednesday, Friday. Review of shower sheets showed no record of a shower completion sheet being completed by staff documenting a shower was completed. Review of shower documentation for the month of January 2023 revealed that Resident R17 only had showers documented on 1/2, 1/4, 1/13, 1/20, 1/23, 1/25, 1/27, and 1/30 and not completed three days per week per the resident's schedule and preference. Review of Resident R59's most recent MDS completed on 11/15/22, revealed in section G0120 bathing self-performance as physical help in part of bathing activity and support provided as one person physical assist. In the past 30 day period, one day was acknowledged as shower provided for Resident 59. An interview with Resident R59, with a BIMS of 11/15, on 1/28/23, indicated he/she struggles to get a shower, indicating they never have enough staff to get a shower. Resident R59 stated, there is always an excuse. 28 Pa. Code 211.12(d)(4) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(3) Management

Based on review of facility documents and policies, and staff and resident interviews it was determined that the facility failed to ensure that the facility had timely follow-up regarding meeting concerns and resolutions for six of six Resident Council attendants (Residents R1, R7, R11, R13, R49, and R49). Findings include: Review of a facility policy entitled Resident Council dated 6/15/16, indicated that the 'facility shall communicate its decisions to responses to resident and/or family group. Review of three of the Resident Council meeting minutes from November 2, 2022, December 8, 2022, January 5, 2023 and January 25, 2023, lacked documentation of resident identified concerns and facility responses to concerns from each of the prior meetings related to lack of showers not being given. Under New business, there lacked evidence that discussions and concerns were communicated to the residents and/or family group. During a resident council interview on 1/29/23, between 10:00 a.m. and 10:30 a.m. six resident council members elicited concerns that they do not hear back from the facility when concerns are voiced. During a review of Resident concern form dated 1/5/23, revealed concerns regarding showers are not being given on appropriate days/ times. Aides are stating that they can't do them because because staffing is short. There is no documented response to the concern. During an interview on 1/29/23, at 9:45 a.m. the Nursing Home Administrator and Activities Staff Member, confirmed that the Resident Council meeting minutes lacked evidence of facility follow-up to resident concerns form and how the facility responded to resident concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(j) Resident rights

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide services to reasonably accommodate needs and preferences by not providing a functional call system for one of 15 residents reviewed (Resident R9). Findings include: No facility policy was provided regarding facility services relating to resident call bells/call bell systems. Resident R9's Admission Record revealed an admitted [DATE], with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (a type of stroke that occurs as a result of disrupted blood flow to the brain), vitamin D deficiency, muscle wasting and atrophy (thinning of muscle mass), and history of unstageable pressure ulcer of sacral region (full thickness tissue loss in which the base of the ulcer is covered by slough and/or extensive necrotic tissue located at the base of spine). Review of the Minimum Data Set (MDS-periodic review of resident care needs) Section G- Activities of Daily Living (ADL) Assistance dated 1/06/23, indicated that Resident R9's Function Limitation in Range of Motion - Upper extremity (shoulder, elbow, wrist, hand) indicates impairment on both sides. Cognitive Patterns noted in a care plan meeting dated 1/06/23, indicated that Resident R9's Brief Interview for Mental Status Score (BIMS) was 6 which is indicative of severe cognitive impairment. A review of Resident R9's care plan dated 1/11/23, indicated that Resident R9 had an ADL self-care performance deficit related to impaired vision, impaired balance during transitions, limited range of motion to bilateral upper and lower extremities with interventions to encourage the resident to use bell to call for assistance. A review of Interdepartmental (IDT) Notes Version 3.0 dated 1/06/23, revealed during a care plan meeting, Resident R9's family member questioned if Resident R9 could get a new type of call bell since he/she is unable to press the call bell button. Observations on 1/29/23, at 11:00 a.m. and 2:15 p.m. revealed Resident R9's call bell hanging off left side of bed dangling down to floor and not within Resident R9's reach. An observation on 1/30/23, at 2:15 p.m. revealed Resident R9's call bell dangling from the left side of bed down to floor and not within Resident R9's reach. Further observation of Resident R9 revealed contractures to hands. During an interview with the Director of Nursing (DON) on 1/30/23, at 2:30 p.m., it was confirmed that Resident R9's call bell was not within reach. The DON further confirmed Resident R9's call bell could not be utilized by the resident due to contractures and inability to move upper extremities; and the facility failed to ensure a functional call bell system for Resident R9 was provided. 28 Pa. Code 201.18(b)(2)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of an event report submitted to the State Survey Agency, clinical records, facility incident reports, observations and staff interviews, it was determined that the facility failed to identify the accident hazard created when an air mattress was applied to a resident bed equipped with side rails resulting in a fatal accident for one resident (Resident R1). Findings include: Resident R1's face sheet disclosed a facility admission date of [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Set assessment (MDS - periodic assessment of care needs), dated [DATE], revealed that Resident R1 rarely understood verbal communications, was too confused to participate in a mental assessment and required extensive assistance of the staff for all activities, including bed mobility for which she required at least two staff members for turning and repositioning. The assessment also indicated that Resident R1 had one Stage 3 pressure ulcer (an injury to the skin with full thickness skin loss over a bony prominence as a result of pressure), was at risk for the development of pressure ulcers and received pressure ulcer care. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Side Rail Assessment forms for Resident R1 showed that the most recent side rail assessment was completed on [DATE], and the assessment indicated that two half side rails served as an enabler to promote independence. There was no evidence that a side rail assessment or re-evaluation to determine whether changing the bed mattress to an air mattress presented a risk of resident entrapment between the mattress and the side rail. A facility incident/accident report dated [DATE] at 4:30 a.m., disclosed that Resident R1 was found on the floor beside the bed laying on the resident's left side with reddened areas to the left and right feet, left hip, left knee and left elbow. Two upper half side rails were noted to be used. A physical therapy screen was recommended and documented as completed on [DATE]. An additional facility incident/accident report dated [DATE], disclosed that Resident R1 was observed by Licensed Practical Nurse, Employee E2, resting quietly in bed at 8:30 p.m. The resident was next observed when Nurse Aide, Employee E1, entered the resident's room and discovered Resident R1 on the floor at 10:00 p.m., with his/her head positioned between the side rail and mattress. The resident had visible bruising to the neck, had no pulse, no blood pressure and was not breathing. An event report to the State Survey Agency documented that on [DATE], at 10:00 p.m., Resident R1 was found positioned with the resident's body on the floor and head between the side rail and mattress. At this time the resident was found to be unresponsive with neck bruising and was pronounced deceased by the Registered Nurse. On [DATE], at 12:20 p.m., observations of Resident R1's bed, with the Director of Nursing and Nursing Home Administrator present, revealed that the air mattress compressed when pressure was applied near the side rails creating a space large enough to allow a resident to be entrapped between the mattress and side rail. During interviews on [DATE], at 10:05 a.m. until 10:20 a.m., Nurse Aide, Employee E1, and Licensed Practical Nurse, Employee E2, confirmed that on arrival to Resident R1's room at the time of the incident on [DATE], they discovered the resident with his/her body on the floor next to the bed and his/her head and neck trapped between the mattress and side rail. They stated that when the Registered Nurse immediately responded, the staff had to pull the mattress out in order to free the resident and that the resident appeared to have expired. During an interview on [DATE], at 11:08 a.m., the Director of Nursing and Nursing Home Administrator confirmed that there was no indication that an assessment was completed to determine whether the application of an air mattress with side rails, presented the risk of resident entrapment. The facility failed to identify the accident hazard created by the use of the side rails in conjunction with an air mattress. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE]. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(c) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE].