Every finding on record at Manor at St Luke Village,The

Based on a review of the facility's planned menu, weekly menu cycle, and menu extensions, as well as resident and staff interviews, it was determined that the facility failed to ensure planned menus were sufficiently reviewed and updated to provide adequate variety and to prevent repetitive meal selections in accordance with resident preferences which affected 5 out of 8 residents interviewed, who reported experiencing repetitive meals and limited variation in menu selections that did not reflect their stated food preferences.Findings included: During a Resident Council meeting conducted on January 6, 2026, at 10:00 AM, concerns were raised regarding the lack of variety in the facility's menu. Residents, 34 and 70, indicated that they have a problem with the variety of options on the menu. Residents 34 and 70 explained that the facility continuously serves chicken and pork. Resident 34 indicated that residents have made suggestions during resident group meetings regarding food that they enjoy and would like to see more often, but there has been no action by the facility to address resident concerns. During an interview on January 5, 2026, at 10:40 AM, Resident 53 stated he was frustrated with the menu because the facility continuously serves chicken and pork. He indicated that it is always chicken and pork, and he is sick of the menu. During an interview on January 5, 2026, at 11:30 AM, Resident 5 reported the menu frequently contained repetitive food items, particularly chicken, and lacked variety. She stated the menu choices are not representative of the local area and foods she was accustomed to. She expressed dissatisfaction with pinto beans served as the main entree and stated, Corporate must be from down South. Resident 5 reported that she voiced these concerns during prior Food Committee meetings but felt her concerns were not addressed. During an interview on January 6, 2026, at 9:30 AM, Resident 88 stated she has a problem with the food because the dietary department serves so much chicken. She indicated that she wished the facility had more options for residents. A review of the Fall/Winter 2025-2026 menu, signed by the Registered Dietitian on December 4, 2025, revealed multiple instances of repetitive meal entree patterns throughout the 4-week menu cycle: A review of week 1, revealed Sunday the planned entree for lunch was chicken alfredo and then for lunch on Monday, the planned lunch was chicken tenders, with chicken served for consecutive meals. Monday week 1 dinner, the planned entree was beef and bean chili, and the planned entree for lunch on Tuesday was lasagna with meat sauce, and the planned entree on Wednesday dinner was Salisbury steak (beef), with beef served for consecutive meals. The planned entree for Friday week 1 dinner was BBQ pork platter, and the planned entree for Saturday lunch was BBQ pork on a bun, with pork served for consecutive meals. Sunday week 2, the planned entree for lunch was meat sauce with noodles, and the planned entree for dinner on Monday was sloppy joe on a bun (beef), and the planned entree for Tuesday lunch was cheeseburger on a bun, and the planned entree for Wednesday dinner was meatloaf, and the planned entree for Thursday was beef soft tacos, with beef served for consecutive meals. Sunday week 2, the planned entree for dinner was rotisserie chicken, and the planned entree for lunch on Monday was BBQ chicken thigh, and the planned entree for dinner on Tuesday was maple Dijon chicken breast, and the planned entree for lunch on Wednesday was fried chicken, and the planned entree for dinner on Thursday was marinated chicken breast, with chicken served for consecutive meals. These repetitive meal patterns demonstrated that the facility failed to provide sufficient variety within the planned menu cycle, contributing to resident dissatisfaction and menu fatigue. During an interview on January 7, 2026, at 11:50 AM, the Dietary District Manager stated the regional corporate office was responsible for providing the facility with a 4-week seasonal menu, which was reviewed by the facility's Registered Dietitian. She further stated that the facility offered a resident choice meal one time per month, determined by attendees at Food Committee meetings. During an interview on January 8, 2026, at 10:00AM, the Nursing Home Administrator confirmed that similar foods were served for consecutive meals. The facility failed to ensure the planned menus were adequately reviewed and modified to provide sufficient variety and reflect resident preferences, resulting in repetitive meal patterns that did not meet the satisfaction of the residents. Refer F56528 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.6 (a) Dietary services.

Based on observations, a review of select facility policy, clinical record review, and staff and resident interviews it was determined the facility failed to timely evaluate nutritional requirements to ensure acceptable parameters of nutritional status for two of 26 sampled residents were being maintained (Residents 5 and 29).Findings include: A review of the facility's policy entitled Weight Monitoring, reviewed July 24, 2025, identified that weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or unhealthy weight loss over a period of time may indicate a nutritional problem. The facility will utilize a systematic approach to identify residents at risk, evaluate and analyze the assessment information, implement pertinent approaches, and monitor the effectiveness of these approaches. Further it was indicted a weight monitoring schedule will be developed upon admission for all residents. Newly admitted residents will have weights monitored weekly for four weeks and then monthly thereafter. Residents with identified weight loss will be monitored weekly. Significant weight changes would include a 5% change in weight in one month, a 7.5% change in 3 months, or a 10% change in 6 months. Meal completion information should be recorded and may be referenced by the interdisciplinary team as needed.A review of Resident 5's clinical record revealed admission to the facility on January 26, 2017, with diagnoses which included muscle wasting. A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2025, revealed the resident's BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact) and was wheelchair bound.During an interview conducted with Resident 5 on January 5, 2026, at 11:30 AM, the resident reported transfers were completed using a mechanical lift (a powered medical device used to lift and transfer residents safely). The resident reported being weighed either by mechanical lift or while seated in a wheelchair and denied participating in activities that would reasonably account for large fluctuations in body weight gain/loss. A review of Resident 5's weight records from July 4, 2025, through January 7, 2026, revealed multiple significant weight changes, including both substantial loss and gain:July 4, 2025- 268.5 lbs.August 1, 2025- 268 lbs.August 3, 2025- 268 lbs.September 1, 2025- 280.5 lbs.November 1, 2025- 234.5 lbs.November 11, 2025- 234.5 lbs.December 1, 2025- 234.5 lbs.January 3, 2026- 299.8 lbs.January 7, 2026- 298 lbs. The record lacked documented evidence that reweighs were obtained to verify the accuracy of these extreme variations. An interdisciplinary note dated November 5, 2025, at 8:31 AM, indicated the resident experienced a 7.5 percent weight loss since August 3, 2025 (weight variation from 268 lbs. to 234.5 lbs.), however, review of documented weights revealed a greater degree of fluctuation. Specifically, the change from September 1, 2025 (280.5 lbs.) to November 1, 2025 (234.5 lbs.) represented a 16.4 percent weight loss, and the change from December 1, 2025 (234.5 lbs.) to January 3, 2026 (299.8 lbs.) represented a 27.85 percent weight gain. The clinical record lacked evidence that these extreme fluctuations were questioned, validated, or investigated to determine whether contributing factors such as medical conditions, equipment consistency, weighing method, or staff practices were influencing weight accuracy. There was also no evidence that nutritional parameters were reassessed to ensure the resident's nutritional status remained acceptable. During an interview conducted with the dietician on January 6, 2026, at 1:30 PM, it was confirmed that Resident 5 experienced weight fluctuations exceeding the facility's defined thresholds for significant weight change. of 5% in 30 days, 7.5% in 3 months, and 10% in six months. A review of Resident 29's clinical record revealed admission to the facility on December 17, 2025, with a diagnosis that included muscle weakness (a condition that may affect mobility, endurance, and nutritional needs). An admission MDS dated [DATE], indicated the resident had a BIMS score of 14, reflecting intact cognition. During an interview conducted with Resident 29 on January 5, 2026, at 10:00 AM, the resident reported not eating due to dissatisfaction with meals offered, specifically meals containing beef, which the resident reported were not recommended by his physician. The resident further reported experiencing weight loss.A review of Resident 29's weight record revealed that on admission the resident was 137 lbs. December 20, 2025: 131.5 lbs.December 23, 2025: 134.5 lbs. A scheduled weigh-in on December 30, 2025, was refused by the resident. The next documented weight was obtained on January 6, 2026, which indicated the resident weighed 123.5 lbs., representing a 9.85 percent weight loss from admission. The clinical record lacked evidence that additional attempts were made to obtain a timely reweight following the refusal on December 30, 2025, to identify potential ongoing weight loss and implement interventions prior to the documented January 6, 2026, weight. An observation of Resident 29's lunch meal on January 5, 2026, at 11:42 AM and again at 12:15 PM, revealed the resident consumed 0 percent of the meal. Review of meal completion documentation for the same period reflected intake inaccurately documented between 26 percent and 50 percent. During an interview conducted with the dietician on January 8, 2026, at 1:30 PM, it was confirmed that meals containing beef were served on December 18, 25, 26, and 30, 2025, and January 5, 6, and 7, 2026. The dietician indicated that Resident 29 was offered alternative meals that did not consist of beef; however, they were unable to provide evidence of what those meals were and if acceptable meal completion was noted for those alternatives to evaluate if the weight loss was in conjunction with either poor meal completion, resident preference, staff accuracy documenting meal completion, or a combination of all the above. The dietician also confirmed that no additional weights were attempted following the December 30, 2025, refusal prior to the documented 13.5-pound weight loss identified on January 6, 2026. The facility failed to provide evidence that significant weight changes were accurately verified, timely identified, thoroughly assessed, and appropriately acted upon for Residents 5 and 29. The facility further failed to ensure consistent weighing practices, accurate meal intake documentation, and timely nutritional interventions to maintain acceptable parameters of nutritional status. 28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on observations, review of manufacturer recommendations, and staff interviews, it was determined that the facility failed to ensure a safe and orderly environment related to the placement of a personal appliance for one of 12 residents sampled who had personal refrigerators (Resident 23). Findings include: An observation conducted in Resident 23's room on January 5, 2026, at approximately 10:00 AM, revealed the resident had a personal refrigerator located on top of a bedside cabinet. The bedside cabinet did not adequately accommodate the full base of the refrigerator. Observations revealed that a portion of the refrigerator base extended beyond the edge of the cabinet, resulting in an unbalanced surface (one in which the weight of an object is not evenly distributed across its supporting base, creating a risk for tipping or falling). The refrigerator was three feet off the ground, further increasing the potential for injury should the appliance fall. A review of the refrigerator manufacturer's instruction manual indicated that the appliance was required to be placed firmly on a flat, stable surface that fully supports the size and weight of the unit to prevent tipping, shifting, or falling. During an interview conducted on January 5, 2026, at 1:30 PM the Nursing Home Administrator acknowledged the refrigerator was not appropriately sized to be placed on the bedside cabinet. 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management

Based on a review of facility policy, Resident Council meetings minutes, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by five of five residents attending a resident group meeting (Residents 8, 11, 16, 34, and 70), and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's Resident and Family Grievances policy, last reviewed on July 24, 2025, revealed grievances may be voiced as a verbal complaint to a staff member, a written complaint to a staff member, or a verbal complaint during resident or family council meetings. The policy indicated the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident to complete the form. The facility will take steps to resolve the grievance and record information about the grievance and those actions on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow-up. The policy indicated the facility will take prompt efforts to resolve the grievance (including acknowledgment of a complaint or grievance and actively working toward resolution of that complaint or grievance). A review of food committee meeting minutes dated October 7, 2025, revealed residents in attendance requested the menu to include more soups with meat, pierogies, and more cooking demonstration activities (an activity with dietary services to review menu options and an opportunity for resident feedback). Residents in attendance raised concerns about being able to choose snacks and snacks not arriving with labels. A review of food committee meeting minutes dated November 4, 2025, revealed residents in attendance would like the menu to include more pierogies, Polish foods, soups, and meal options at dinner and to have more cooking demonstrations. A review of food committee meeting minutes dated December 2, 2025, revealed residents in attendance indicated complaints that fish and pork are not generally liked, snacks are refused often because the snacks are labeled with resident information, and there are no snack options. Residents also identified food items they would like to include: fish, stewed tomatoes, and crab cakes. During a resident group interview on January 6, 2026, at 10:00 AM, with alert and oriented residents that normally attend resident council meetings, five of five residents (Residents 8, 11, 16, 34, and 70) indicated when they bring up food concerns at meetings, the facility does not respond to their concerns. Residents 8, 11, 16, 34, and 70 indicated they continue to have concerns about dietary services such as the menu, food temperature, meal variety, and snacks. Residents 8, 11, 16, 34, and 70 indicated that the facility does not respond to the group's concerns about these issues, and their concerns have not been resolved. During the interview, Resident 16 indicated that she had concerns that she does not always receive a snack. During the interview, Resident 34 indicated that she was upset because she was given a snack each night without having the option to make a choice. She explained the snacks arrive with her name on them, and she cannot make a choice about what snack she would like. Resident 34 also indicated that the menu variety was limited and they are served too much pork and chicken. She also indicated the food was not hot. Resident 34 explained that she has brought these issues up during each meeting, but there have been no attempts to resolve these concerns for several months. During the interview, Resident 70 indicated that sometimes she was not offered a snack, and the fresh fruit she was served was hot because of the manner it was stored on the serving trays. She also indicated that the facility serves the same foods, and she would like more variety. Resident 70 explained that residents have made recommendations for foods they enjoy, but the facility does not respond to their concerns about food. During the interview, Resident 8 indicated that she had raised concerns about snacks at previous meetings, but nothing has been done to address her issues. She indicated she reported enjoying ice cream as a snack but was only provided a sandwich that she does not eat. Resident 8 also indicated that her eggs are served cold and the coffee was not hot. She confirmed these issues have not been resolved, despite raising the issues during group meetings. During the meeting, Resident 11 indicated that he was offered a snack every day but does not have a choice in what was served. Resident 11 explained that the same item was delivered each day, and he does not have an option. He also indicated that his fresh fruit was served hot because it was transported on the hot portion of his tray. Resident 11 confirmed that residents have brought these issues up at meetings, but the issues have not been resolved. During an interview on January 7, 2026, at 12:55 PM, the Registered Dietician confirmed she meets with the resident groups to discuss food and dietary services each month. The Registered Dietician was unable to provide documented evidence that the facility was resolving and addressing complaints and grievances residents raise during group meetings. During an interview on January 8, 2025, at 10:45 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that the facility was addressing, responding to, or resolving resident complaints and grievances related to food and dietary services raised during resident group meetings. The facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during resident group meetings, including those voiced by Residents 8, 11, 16, 34, and 70. Refer F80328 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.12 (d)(3) Nursing services.

Based on observations, select policy review, and staff interview, it was determined the facility failed to ensure that food storage in personal refrigerators were adequately monitored and maintained within safe temperatures to prevent foodborne illness for one of 12 residents with personal refrigerators (Resident 23).Findings include: Review of the facility policy entitled Safe Food Handling for Foods from Visitors last reviewed July 24, 2025, revealed that residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Staff will request that visitors notify someone from the activities or nursing department when a food item is brought in for immediate consumption or for something to be consumed at a later date. Food intended for later consumption will have labels placed on the item by staff, which will indicate the resident's name and current date. Foods noted to be 7 days or older from when placed into the refrigerator are to be discarded. Further it was indicated refrigerators storing food will be maintained and monitored on a daily basis to ensure the temperature inside the refrigerator is 41 degrees Fahrenheit or less. An observation of Resident 23's room on January 5, 2026, at approximately 10:00 AM revealed the resident had a personal refrigerator in the room. Upon opening the refrigerator, it was noted the temperature inside the refrigerator was approximately 48 degrees Fahrenheit. It was also noted that there was an unlabeled container of food that was not dated as to when or how long the item was stored in the refrigerator. An observation of Resident 23's refrigerator on January 5, 2026, at 1:30 PM with the nursing home administrator revealed and confirmed that the temperature inside the refrigerator was 48 degrees Fahrenheit and that the food in the container was not labeled with a date or the resident's name. The nursing home administrator indicated that staff are to monitor the temperature inside the refrigerator daily, and this should be recorded. A review of Resident 23's refrigerator temperature logs for January 2026 revealed staff were only to take action for refrigerator temperatures exceeding 46 degrees Fahrenheit, which was not in conjunction with facility policy for safe food storage. In addition, on January 1, 2026, and January 4, 2026, there was no evidence that monitoring Resident 23's refrigerator was completed. On January 2, 3, and 5, 2026, the temperature inside the refrigerator was noted to be 42 degrees Fahrenheit, which was above the appropriate temperature as outlined in facility policy. The interview with the nursing home administrator on January 6, 2026, at 9:00 AM, was unable to provide additional information that would explain why staff monitoring inside refrigerator temperatures were not aware of the facility policy for safe food storage, why the temperature logs directed staff to only intercede with refrigerator temperature regulation after temperatures exceeded 46 degrees Fahrenheit, and why this resident's food was not appropriately labeled and date. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on clinical record review, select facility policy review, investigative documentation provided by the facility, and staff interviews it was determined the facility displayed past non-compliance by failing to ensure the safety and supervision of one resident identified at risk for wandering and elopement from exiting through unsecured doors for one out of 26 residents sampled (Resident 89). Findings include: A review of the facility policy titled Elopement/Wandering Risk Guideline, last reviewed by the facility on July 24, 2025, revealed it is the policy of the facility to evaluate and identify residents that are at risk of elopement and develop individualized interventions. A review of the facility policy titled Missing Patient/Resident, last reviewed by the facility on July 24, 2025, revealed it is the policy of the facility that staff will investigate cases of missing residents and possible elopement. Further review revealed that elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so, placing the resident at risk for harm or injury. A review of the clinical record revealed that Resident 89 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of the resident's quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated July 9, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 07 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 to 7 indicates severe cognitive impairment). A review of the resident's care plan initiated June 14, 2023, revealed Resident 89 was identified as being at risk for elopement related to impaired safety awareness, with an established goal that the resident would not leave the facility unattended. A review of an elopement risk assessment dated [DATE], identified the resident as being at low risk for elopement. A review of a nursing progress note documented by Employee 4 (Registered Nurse, RN) dated August 16, 2025, at 12:51 AM, revealed that Resident 89 exited the facility without being observed by staff and was located in the facility parking lot. The resident was returned to the facility without incident. A body check was completed, and the resident was noted to be in stable condition. The physician and resident representative were notified, and a wander guard bracelet, defined as an electronic monitoring device used to alert staff when a resident approaches or exits a secure area, was applied to the resident's left wrist. A review of a written witness statement dated August 15, 2025, from Employee 5 (Nurse Aide) revealed that during routine rounds at approximately 10:00 PM, the employee assisted the resident in bed one and then proceeded to bed two, identified as Resident 89. The employee observed Resident 89 up in his wheelchair. The employee asked if the resident required incontinence care, which the resident declined, stating he was okay. The employee then exited the room. The employee reported she did not observe the resident in the corridor at that time and did not note the resident to be upset or distressed. A review of a written witness statement dated August 15, 2025, from Employee 7 (Licensed Practical Nurse) revealed resident care was provided throughout the shift, and at no time did Resident 89 verbalize an intent to leave the facility. The employee stated the resident was present in his room prior to the incident. The employee further reported taking a 15-minute break at approximately 10:00 PM in the back parking lot and did not observe any individuals in the parking lot at that time. A review of a written witness statement dated August 15, 2025, from Employee 8 (Licensed Practical Nurse) revealed the employee was working on the upper east unit with another resident and observed Resident 89 pass by in his wheelchair. The employee indicated no immediate concern was raised because the resident was known to occasionally go to the front area of the building during the evening hours. A review of a written witness statement dated August 15, 2025, from Employee 4 (Registered Nurse) revealed the resident was later identified to have exited the facility. The employee stated the resident had previously been observed in his bed during routine rounds conducted by nursing staff. The resident was subsequently returned to the facility without incident. A body check was completed, and the resident was noted to have no apparent injuries or ill effects. The resident was described as alert and aware and stated he had gone outside to get fresh air. Vital signs were obtained, and the physician and resident representative were notified. A wander guard was applied to the resident. A review of a written witness statement dated August 16, 2025, from Employee 6 (Licensed Practical Nurse) revealed that at approximately 10:10 PM on the evening of August 15, 2025, the employee was completing end-of-shift documentation when alerted by a notification from the phone camera at the front door. The employee observed an individual looking into the camera and heard the individual request assistance, stating there was a man in a wheelchair outside who had provided his name. The employee recognized the name as a resident and, upon approaching the front door, observed Resident 89 seated in his wheelchair outside the building. A review of a written witness statement dated August 16, 2025, from Employee 9 (Receptionist) revealed the employee stated the front door had been locked at approximately 8:00 PM prior to leaving for the day. The employee further indicated they checked the exterior of the door before leaving for the day. A review of a physician order dated August 16, 2025, revealed an order was obtained for application of a wander guard bracelet and for staff to check placement each shift. A review of an elopement risk assessment dated [DATE], revealed Resident 89 was reassessed and identified as being at high risk for elopement. During a telephone interview conducted January 7, 2026, at 2:20 PM, Employee 5, a Nurse Aide, confirmed she had completed routine rounds, assisted the resident shortly before the incident, and learned approximately ten minutes later that the resident had been found outside the building. During an interview conducted January 7, 2026, at 1:00 PM, the Nursing Home Administrator confirmed the facility did not have a proper locking process in place at the time of the elopement and that a new locking system was implemented following the incident on August 15, 2025. These findings demonstrated the facility failed to ensure effective supervision and implement adequate environmental and monitoring safeguards for a resident with impaired cognition and impaired safety awareness, resulting in an unsupervised exit from the facility. This deficiency is cited as past noncompliance. The facility's corrective action plan was to identify other residents with the potential to be affected, and a headcount was completed, all door locks were checked, and residents with wander guards were checked for placement and function on August 15, 2025. Education was provided, starting on August 15, 2025, regarding alarming the front door for RN supervisors immediately. On August 16, 2025, another facility-wide check of all doors and door locks was completed, windows were checked to ensure proper opening compliance and good repair, and the Wander Guard system was checked to ensure proper function. Elopement assessments were initiated and completed on all residents. Any newly identified residents with high scores for risk of elopement had their plans of care reviewed to ensure accuracy and appropriate interventions. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to facility staff regarding the facility's elopement policy, including procedures and protocols, initiated on August 16, 2025, with completion on August 19, 2025. Registered Nurses were educated on the alarm setting protocol that was in place immediately, in which protocols were in place and were locking the doors as of August 16, 2025. A new system for unmanned front door building access for after-hours was implemented on August 19, 2025. This included locking the front doors and unlocking the front doors for the process of after-hours entrance and exit. Additional education was initiated on August 19, 2025, and was completed before starting the shift. To monitor and maintain ongoing compliance, the facility completed two elopement drills on each shift throughout the month of August to ensure elopement protocols are followed. The findings of the plan of correction were submitted to QAPI for review. The facility's immediate corrective action plan was completed on August 28, 2025. A demonstration of the door locking with the new locking system protocol was conducted on January 7, 2026, at 1:00 PM, by Employee 2 and observed by the surveyor without any concerns.28 Pa Code 201.14(a) Responsibility of Licensee.28 Pa Code 201.18(b)(1) (e)(1) Management.28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records and staff and resident interviews, it was determined the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision and arrange for treatment by a professional specializing in the provision of vision assistive devices as needed for one out of 26 residents sampled (Resident 6).Findings include: A review of the facility policy titled Hearing and Vision Services, last reviewed by the facility on July 24, 2025, revealed it is the policy of the facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as needed. Further review revealed that staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that included diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood and urine) and end stage renal disease and was dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 29, 2025, revealed that Resident 6 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A clinical record review revealed that Resident 6's last evaluation for visual acuity (a test to determine how clearly a person can see, the ability to see details and objects at near or far distances, with or without glasses) was on July 3, 2025, with follow up noted in six to nine months. A review of a nursing progress note dated November 17, 2025, at 11:59 AM, revealed there was a new optician (person qualified to make and supply eyeglasses for correction of vision) consult related to a decrease in vision since the resident's last dialysis visit. A review of a physician's order dated November 17, 2025, at 12:00 PM, revealed an order for an optician consultation due to a decrease in vision since the last dialysis visit. A clinical record review at the time of the survey on January 7, 2026, revealed no evidence that the resident was seen by an optician. During an interview with the Nursing Home Administrator (NHA) on January 7, 2026, at 1:00 PM, it was revealed that the resident was due to be seen by the optician on his next follow up appointment on February 25, 2026, and it was confirmed that an appointment was not made for him other than his follow up appointment, despite a physician's order for one. During an interview with Resident 6 on January 8, 2026, at 12:00 PM, the resident revealed he had been experiencing decreased vision for several months and felt like his glasses needed some adjustment. The facility failed to ensure Resident 6 received proper treatment and assistive devices to maintain vision and arranged for treatment by a professional specializing in the provision of vision assistive devices. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a discharge plan that accurately reflected a resident's discharge goal or preferences for two out of 26 residents reviewed (Residents 3 and 40).Findings included: A review of the facility policy entitled Discharge of Resident to Home or Other Center, last reviewed by the facility on July 24, 2025, revealed it was the policy of the facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals and the preparation of the residents to be active participants in the discharge planning process. The policy indicated the facility will determine the resident's expected goals and outcomes regarding discharge upon admission, during care plan meeting reviews, and as needed. The policy further indicated if discharge to the community was determined to be unsafe and unrealistic goals are identified, the facility will document in the clinical record who made the determination and why. The policy revealed the evaluation of the resident's discharge needs and discharge plan will be completely documented in a timely manner in the resident's clinical record. A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 20, 2025, revealed Resident 40 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A review of the quarterly MDS dated [DATE], Section D0150 Resident Mood Interview (Patient Health Questionnaire series, a set of self-report questionnaires for screening and monitoring depression) revealed Resident 40 indicated he had been feeling down, depressed, or hopeless two to six days over the past two weeks. Further review of the quarterly MDS dated [DATE], Section Q0400 Discharge Plan, revealed active discharge planning for Resident 40 to return to the community was not occurring. A review of the resident's current plan of care initiated on February 8, 2022, indicated Resident 40 wished to remain a long-term care resident. Interventions included evaluating the resident's motivation to return to the community. Further review of Resident 40's care plan dated February 18, 2022, revealed the resident had a decline in activities of daily living (ADLs, fundamental self-care tasks like bathing, dressing, eating, toileting, transferring or moving, and continence, used to measure a person's functional independence). Interventions indicated the resident was independent with bed mobility, dressing, eating, transferring, toilet use, and personal hygiene. Further it was noted the resident was independent-supervision with one staff member for showering or bathing. A progress note dated June 7, 2025, at 9:29 AM revealed Resident 40 was in long-term care, as his wife cannot manage his care at home. A progress note dated July 16, 2025, at 8:00 PM revealed Resident 40 would like to go home and be with his wife. The resident noted his feelings of depression and anxiety were related to being in a nursing home. A progress note dated October 1, 2025, at 8:00 PM revealed Resident 40 wanted to go home and be with his wife. The resident rated his depression and anxiety as four out of ten, with ten being the worst. The note indicated that his mood was terrible related to wanting to go home. A progress note dated December 10, 2025, at 5:00 PM revealed Resident 40 stated his wife was home alone and he would like to go home and help her. The resident rated his depression and anxiety as six out of ten, with ten being the worst. The resident's mood was indicated as miserable related to him wanting to go home. Further it was indicated solution-focused therapy was utilized to help Resident 40 brainstorm possible solutions for these issues. During an interview on January 5, 2026, at 10:55 AM, Resident 40 explained that he does not want to remain in the facility. He indicated that his preference and goals are to be discharged home. Resident 40 explained that he was ambulatory, independent, and takes care of himself. He indicated that the facility staff have told him he was not safe to be discharged . During an interview on January 6, 2026, at 12:22 PM, Employee 1, Social Services Assistant, confirmed Resident 40 had indicated he would like to go home in the past. She confirmed that discharge planning has not been initiated. Employee 1 confirmed that the resident's care plan does not match his wishes and preferences to return to the community. During an interview on January 8, 2026, at 10:45 AM, the Nursing Home Administrator (NHA) confirmed the facility was not actively working on Resident 40's discharge and that Resident 40's care plan did not accurately include his preferences and wishes to return to the community. The NHA was not able to provide documented evidence indicating the clinical rationale preventing Resident 40 from returning to the community. The facility failed to develop and implement a discharge plan that accurately reflected Resident 40's discharge goals, preferences, and/or included barriers preventing the resident's discharge to the community. A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include encephalopathy (broad term for any disorder or disease affecting the brain's function, causing confusion, memory loss, personality changes or altered consciousness), bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and schizophrenia (a severe, chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to interpret reality abnormally through symptoms like hallucinations and delusions). A review of an admission MDS assessment dated [DATE], revealed that Resident 3 was cognitively intact with a BIMS score of 14. Further review of the resident's admission MDS assessment revealed Section Q (a section used for resident goal setting) indicated the resident's overall discharge plan was to discharge to another facility and/or institution. A review of a Social Services progress note dated May 13, 2025, at 4:18 PM, indicated the care plan meeting was held with the Interdisciplinary Team and Resident 3's brother. During the meeting, Resident 3's brother indicated the discharge plan was for long-term care. A review of Resident 3's comprehensive care plan, initiated on April 12, 2025, revealed the current care plan did not identify or address a discharge plan, including transfer to another facility or remaining in the facility for long-term placement, despite documented discharge discussions and decisions. During an interview with the Director of Nursing (DON) on January 7, 2026, at 11:35 AM, the DON confirmed that discharge planning information was absent from Resident 3's care plan prior to the survey. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 201.18(e)(1) Management.28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (d)(3) Nursing services.

Based on clinical record review, select facility policy, review of resident financial records, and resident and staff interviews, the facility failed to safeguard, manage, or accurately account for the resident's personal funds deposited with the facility for one out of 26 residents sampled (Resident 53).Findings include: A review of the facility policy titled Resident Person Funds, last reviewed by the facility on July 24, 2025, revealed if the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary (an organization that is legally and ethically required to act in the best interest of another person) of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. A review of the facility form titled Resident Trust Fund Notification and Authorization, last reviewed by the facility on July 24, 2025, revealed procedures for residents' withdrawals and purchases. The form indicated that requests for less than $50 for those residents whose care is funded by Medicaid will be honored within the same day. A clinical record review revealed Resident 53 was admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (a blood clot that prevents blood flow to the lungs and potentially causes life-threatening symptoms like sudden shortness of breath, chest pain, and fainting) and rhabdomyolysis (a serious condition where damaged muscle tissue breaks down rapidly, releasing harmful substances into the bloodstream). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 15, 2025, revealed that Resident 53 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). During an interview on January 5, 2026, at 10:40 AM, Resident 53 indicated that he was angry and frustrated because yesterday (Sunday), January 4, 2026, he attempted to retrieve his money from Employee 2, Receptionist, but she reported that she was not able to give him his money because she did not have his account information. Resident 53 expressed that he was angry because he wanted to buy a hoagie. Resident 53 confirmed that later in the evening, Employee 3, Nurse Aide (NA), gave him $10.00 of her own money until the issue was resolved. During an interview on January 7, 2026, at 11:32 AM, Employee 2 confirmed that she did not give Resident 53 his funds on Sunday, January 4, 2026, because she did not have access to his account information. Employee 2 indicated that the resident became upset and yelled. Employee 2 explained that her access to resident account information was not working since August 2025. She indicated that she must speak to the Business Office Manager (BOM) to ensure that residents have enough money before allowing residents to make withdrawals from the petty cash. Employee 2 indicated that on Sunday, January 4, 2026, the BOM was not working, and she did not contact the BOM for Resident 53's personal fund information on January 4, 2025. During an interview on January 7, 2026, at 11:40 AM, the Business Office Manager indicated on January 4, 2026, Resident 53 had $47.17 available. The BOM confirmed that the Receptionist must contact her to know how much residents have in their accounts. The BOM confirmed that she was not contacted on January 4, 2025. The BOM provided a receipt indicating that Employee 3, Nurse Aide, was reimbursed for $10.00. During an interview on January 8, 2025, at 10:45 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The facility failed to ensure residents have access to their personal funds for withdrawals less than $50.00 and ensure a process is in place to accurately account for residents' personal funds. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and interviews with facility staff, it was determined the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for one out of 26 residents sampled (Resident 76).Findings included: A review of the facility policy titled Incontinence, last reviewed by the facility on July 24, 2025, revealed it is the facility policy that residents who enter the facility with an indwelling catheter (a flexible tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods), or receive one while in the facility, will be assessed for removal of the catheter as soon as possible, unless the resident's clinical condition demonstrates that catheterization was necessary. A clinical record review revealed Resident 76 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed that Resident 76 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A clinical record review of a physician's order for Resident 76 dated December 24, 2025, revealed an order for a Foley catheter (a small flexible tube inserted into the urethra to drain urine from the bladder) with a diagnosis of obstructive uropathy (a blockage in the urinary tract that stops urine from flowing out). A review of a nurse practitioner's progress note for Resident 76 dated December 26, 2025, revealed the resident had a Foley catheter inserted during hospitalization prior to admission, and the plan was for a voiding trial (a test in which a urinary catheter is removed or clamped to determine whether a resident can urinate on their own and adequately empty the bladder without urinary retention) and to refer to urology (medical specialty that focuses on the diagnosis and treatment o conditions affecting the kidneys and bladder) if the trial failed. A review of a nurse practitioner's progress note for Resident 76 dated December 31, 2025, revealed the resident had a Foley catheter, and it was unclear if a voiding trial was attempted at the facility, and the plan was for a voiding trial with the Foley catheter to be removed and to straight catheterize (one time insertion of a catheter into the bladder to drain urine). If the resident is unable to urinate in eight hours and to retain the Foley for urine residual (amount of urine left in the bladder after urination) greater than 300 milliliters (ml). A clinical record review at the time of the survey on January 6, 2026, revealed no evidence that the resident had a voiding trial and that the Foley catheter was discontinued. During an interview with Resident 76 on January 6, 2026, at 9:00 AM, it was revealed that the Foley catheter was new for her and it was inserted prior to admission to the facility while she was in the hospital, and she stated she wished it could be removed because it was uncomfortable and burned. An interview with the Director of Nursing (DON) on January 6, 2026, at 12:15 PM, revealed that nursing staff are responsible for reading physician or physician extender notes regarding resident clinical information and recommendations. Following surveyor inquiry, a physician's order was noted on January 6, 2026, at 4:42 PM, for Foley catheter removal and voiding trial, and to straight catheterize the resident if unable to void in eight hours from removal and retain the Foley catheter if there is a residual greater than 300 ml. A clinical record review of a nursing progress note dated January 6, 2026, at 6:53 PM, revealed that the resident was incontinent with a moderate amount of urine at that time. During an interview with the DON on January 7, 2026, at 9:35 AM, it was confirmed that the facility failed to timely reassess the need for catheter placement for Resident 76. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to monitor, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice for one resident out of six sampled residents (Resident CR1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the resident's status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person. Proper documentation and care planning ensure: Monitoring for Symptoms: Identifying signs of device-related complications. Timely Intervention: Staff can promptly address concerns or escalate issues to a physician. Comprehensive Care: Avoiding complications, such as infections at the implant site, through routine assessments and interventions. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses including liver cirrhosis (chronic liver damage from various causes leading to scarring and liver failure) and chronic ascites (abdominal swelling caused by fluid accumulation, most often related to liver disease). A review of a Minimum Data Set (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 25, 2025, revealed that Resident CR1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that assesses the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of a facility policy titled Abdominal or Pleural Intermittent Drainage, last reviewed by the facility on January 23, 2025, required staff to document the condition of the drain site and catheter. Resident CR1 had a left-side thoraco-abdominal drain (a tube inserted to drain fluid from the chest and abdominal cavities) upon admission and underwent an outpatient procedure for placement of a right tunneled peritoneal catheter (a flexible tube inserted into the abdominal cavity to drain excess fluid) on May 12, 2025, while residing at the facility. A review of outpatient interventional radiology (IR) records, provided at the request of the surveyor, showed that after placement of the right tunneled peritoneal catheter, the resident required drainage every other and to call the IR department for any questions, in which a phone number was provided. However, an interview with the Director of Nursing (DON) on June 26, 2025, at 1:00PM, revealed the facility did not have post-procedure care instructions because the family had taken them, and the facility failed to contact the IR department to obtain them. Resident CR1 was sent to the emergency room after this procedure and admitted to the hospital on [DATE], and was re-admitted to the facility on [DATE]. A review of the resident's care plan at discharge and the baseline care plan completed at readmission on [DATE], revealed no specific identification of the right tunneled peritoneal catheter or instructions for its care, including frequency of drainage. The baseline care plan only referenced abdominal drains in general and did not distinguish the two separate sites. A review of physician's orders failed to show any orders for care or monitoring of the newly placed right tunneled peritoneal catheter. A readmission assessment dated [DATE], noted the presence of a right lower quadrant drain site covered by a surgical dressing. Further review of the readmission assessment revealed a nurse's note that stated Resident CR1 had abdominal drain sites on the left upper quadrant and the right lower quadrant, and that the resident stated the right lower surgical dressing cannot be removed until the follow-up appointment, but no follow-up appointment was documented. An interview with the DON confirmed the facility did not inquire about or schedule any follow-up appointment. A review of a change in condition assessment for Resident CR1, dated May 15, 2025, indicated that the resident had a recent hospitalization for a drain repair; however, this documentation was inaccurate, as the hospitalization was for placement of a new right tunneled peritoneal catheter (a flexible tube inserted into the abdominal cavity to drain excess fluid). The same assessment noted that Resident CR1 had a left-side thoraco-abdominal drain (a tube inserted to drain fluid from the chest and abdominal cavities) which was drained for approximately 1000 milliliters every Monday, Thursday, and as needed. The assessment did not include any information about the newly placed right tunneled peritoneal catheter or how often it should be drained. A review of a skin evaluation completed before discharge, dated May 18, 2025, showed no documentation acknowledging the presence of the right tunneled peritoneal catheter. A review of Resident CR1's progress notes likewise revealed no entries describing the right tunneled peritoneal catheter, its care, or monitoring. A review of Medication Administration Records and Treatment Administration Records revealed no documentation related to Resident CR1's right tunneled peritoneal catheter or monitoring. Resident CR1 was sent to the hospital on May 18, 2025, for worsening jaundice (condition marked by yellowing of the skin and eyes caused by increased bilirubin in the blood) and was admitted for sepsis (a life-threatening response to infection) and a mucus plug in the bronchi (airways in the lungs). In an interview conducted on June 26, 2025, at approximately 2:00 P.M., the Nursing Home Administrator and Director of Nursing (DON) reviewed the information outlined above with the surveyor. During this interview, it was discussed that the facility did not provide evidence of continued monitoring of Resident CR1's right tunneled peritoneal catheter, did not obtain appropriate physician orders, and did not implement a care plan to address the catheter. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Medical records.

Based on review clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary use of psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed (PRN) psychotropic medication for two of 19 residents reviewed (Residents 75 and Resident 77). Findings include: A review of Resident 75's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 75's clinical record revealed a physician's order dated January 7, 2025, directed Lorazepam (anti-anxiety medication) 0.5 mg by mouth every eight hours as needed (PRN) for anxiety, for 167 days. A review of the physician's notes for the months of January and February 2025 revealed the physician failed to document the clinical rationale for the continuation of the PRN order beyond the 14-day limit, nor any re-evaluation of the need for the medication. Review of the March 2025 Medication Administration Record (MAR) showed the Lorazepam was administered 25 times. A review of Resident 77's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction (occurs when blood flow to the brain is obstructed, typically by a blood clot, resulting in the death of brain cells) and hemiplegia (one sided paralysis) A review of Resident 77's clinical record revealed a physician's order for Ativan 0.5mg tablet (anti-anxiety medication) 0.5mg by mouth every eight hours as needed (PRN) for anxiety with a start date of February 17,2025 and discontinued March 13,2025. A new order was written March 13, 2025, for Ativan 0.5 mg every eight hours as needed for anxiety, for 90 days. Review of physician notes from February and March 2025 showed no documentation of a clinical rationale or re-evaluation for continuation of the PRN medication beyond 14 days. A review of the resident's March 2025 Medication Administration Record revealed Ativan 0.5mg was administered to the resident 21 times. During an interview conducted on March 27, 2025, at approximately 12:30 PM, the Director of Nursing confirmed that no physician documentation was present to justify the continuation of PRN psychotropic medications beyond the 14-day period, and no periodic re-evaluations were documented 28 Pa. Code 211.2 (d)(3)(7)(9) Medical director. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of scheduled facility mealtimes, resident committee meeting minutes, grievances filed with the facility, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by seven out of nine residents during a group interview (Residents 1, 6, 9, 20, 25, 33, and 83). Findings include: A review of facility policy titled Snacks, last reviewed by the facility on January 23, 2025, revealed it is the facility policy that snacks and beverages will be provided as identified in residents' individual plans of care. Bedtime (HS- hour of sleep) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. A review of the facility's scheduled mealtimes revealed the time between dinner and breakfast the next day exceeds 14 hours. A review of grievances filed with the facility revealed a grievance dated December 5, 2024, indicating residents at resident council raised concerns that nighttime snacks are not always provided or offered. The resolution section of the grievance indicated in-service training was provided to facility staff. A review of food committee meeting minutes dated March 4, 2025, revealed residents in attendance raised concerns that not all residents were receiving nightly snacks. During a resident group interview on March 26, 2025, at 10:00 AM, seven residents in attendance stated they are not consistently offered a nourishing evening snack (Residents 1, 6, 9, 20, 25, 33, and 83). The residents in attendance indicated that sometimes the facility does not have snacks when the residents request them and explained that staff do not always distribute the snacks to residents. The residents in attendance indicated they have brought this concern to staff's attention, but nothing has improved over the last few months. The residents in attendance expressed frustration about not having evening snacks. During an interview on March 27, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) was unable to explain why residents are reporting the facility is not offering nutritious snacks as desired. The NHA confirmed it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with professional standards of care for one out of the 19 residents sampled (Resident 1). Findings include: A review of the facility policy titled Oxygen Therapy, last reviewed by the facility on January 23, 2025, revealed it is the facility policy and procedure to ensure the physician's order for oxygen therapy shall include all of the following: (1) oxygen administration modality, (2) liter flow, (3) as needed or continuous administration, and (4) as needed orders must include specific guidelines as to when the resident is to use oxygen. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 7, 2025, revealed that Resident 1 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed a physician's order that indicated oxygen as needed due to decreased blood oxygen saturation less than SpO2 88%, with direction to provide oxygen as needed, initiated on February 4, 2025. The physician's order did not include the amount of oxygen per liter required to address Resident 1's low blood oxygen saturation. An observation on March 25, 2025, at 10:20 AM, revealed Resident 1 was in her room receiving oxygen via nasal cannula (medical device used to deliver oxygen a thin flexible tube with two prongs that fit into the nostrils) at 2.0 liters per minute (lpm). During an interview at the same time as the observation on March 25, 2025, Resident 1 did not know her prescribed oxygen liter flow rate. An observation on March 26, 2025, at 11:15 AM, revealed Resident 1 was in her room receiving oxygen via nose cannula at 2.0 liters per minute (lpm). During an interview at the time of the observation, the Director of Nursing (DON) confirmed Resident 1 was receiving 2.0 liters per minute of oxygen via nasal cannula. The DON confirmed Resident 1's physician's order did not indicate a flow rate for oxygen administration. Following inquiries made during the week of the survey, Resident 1 had a revised physician's order to receive oxygen at 2.0 liters per minute via nasal cannula due to a decrease in SpO2 to less than 88% as needed, initiated on March 26, 2025. During an interview on March 26, 2025, at approximately 11:30 AM, the Director of Nursing confirmed it is the responsibility of the facility to ensure oxygen therapy is administered in accordance with professional standards of care, which includes ensuring physicians' orders indicate the prescribed oxygen flow rate (i.e., how many liters of oxygen per minute). 28 Pa. Code 211.2 (d)(3) Medical director. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 19 residents reviewed (Resident 58) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses to include Dysarthria (the muscles used for speech are weak or are hard to control. Dysarthria often causes slurred or slow speech that can be difficult to understand) following a cerebral infraction (stroke). Review of a significant change Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated March 2, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating he was cognitively intact. A review of Resident 58's social service notes revealed no social service notes in regard to discharge planning. Resident 58's clinical record did reveal a psychiatry consult dated January 27, 2025 indicating the resident wanted to discharge from the facility. There was no further documentation in Resident 58's clinical record regarding discharge planning. A review of the resident's comprehensive care plan, reviewed during the survey ending March 28, 2025, revealed no documented evidence that an individualized discharge plan was developed, and revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. During an interview with the Nursing Home Administrator on March 27, 2025, at 12:00 PM confirmed there was no documented evidence of a current discharge goal and plan for this resident. 28 Pa. Code 201.18(b)(1) Management

Based on a review of facility policy, resident grievance documentation, clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure a thorough and complete investigation of an allegation of sexual abuse for 1 of 19 sampled residents (Resident 63). Findings included: A review of a facility policy entitled Abuse, Neglect, Exploitation & Misappropriation revealed it is the policy of the facility to provide professional care and services in an environment that is free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Sexual abuse is defined as the nonconsensual sexual contact of any type with a resident which includes but is not limited to unwanted touching of any kind especially of breast or perineal area. Further review of the facility abuse policy revealed under the area of investigation that the Abuse Coordinator or designee will investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. Upon the allegation of abuse or neglect, the suspect will be immediately segregated from residents pending the investigation of the resident allegation. The nurse or Director of Nursing/designee will perform and document a thorough nursing evaluation and notify the attending physician. An incident report will be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. The Abuse Coordinator and/or Director of Nursing will take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she will also secure all physical evidence. Upon completion of the investigation, a detailed report will be prepared. Under the area of reporting, the facility should report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency within 5 working days of the incident. A review of Resident 63's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart does not pump blood as efficiently as it should) and chronic kidney disease (a condition where the kidneys cannot filter blood properly leading to waste buildup). A review of the facility grievance dated February 14, 2025, revealed that Resident 63 no longer wanted Employee 1 to care for her because of the way Employee 1 performed peri-care ((perineal care hygiene of the private areas) made Resident 63 uncomfortable. A written statement from the RN on the 11-7 shift dated February 14, 2025, at 12:00 AM, revealed Resident 63 complained of poor care received on the evening shift. It further revealed Resident 63 stated she felt she is being assaulted when she is getting peri care by Employee 1. A written statement from the NHA dated February 14, 2025, at 8:15 AM documented the NHA asking for additional clarification from the RN on the 11-7 shift. The RN reported Resident 63 said specifically, She didn't like how her hands were on her buttocks and that her fingers went into her rectum and that Resident 63 didn't like the way Employee 1 cleaned her up. Upon an interview conducted on March 26, 2025, at approximately 11 AM, Resident 63 indicated, Employee 1 Put her finger up my a** while performing peri care. The Resident denied sexual or physical harm but stated, It was weird, I did not want her doing that to me again or any other resident. During a telephone interview on March 26, 2025, at approximately 12:00 PM, Employee 1 indicated she no longer works at the facility because of group of residents did not like her due to her race. She further stated she would document care given to Resident 63 but did not perform the care because Resident 63 always refused to let her care for her. The Documentation Survey Report v2 for February 2025 indicated Employee 1 rendered personal hygiene care to Resident 63 on the evening shift of February 13, 2025. Despite this allegation meeting the definition of sexual abuse as outlined by both facility policy and federal regulation, the facility failed to demonstrate a thorough and complete investigation as required. The facility did not: Obtain written statements from witnesses or other staff present. Document a comprehensive nursing evaluation. Notify the attending physician. Complete an incident report. Secure physical evidence. Report the results of the investigation to the State Survey Agency within the required 5 working days. In an interview conducted on March 26, 2025, at approximately 12:45 PM, the NHA and DON acknowledged they were unable to provide evidence that the abuse investigation was completed in response to the resident's allegation. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights

Based on observations, review of the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including upper respiratory infection for 1 of 23 residents reviewed (Resident 1). Findings include: A review of the facility's infection control policy, last revised on January 23, 2025, indicated that the policy was designed to facilitate a safe, sanitary, and comfortable environment while preventing and managing the transmission of infectious diseases The objectives of the infection control policies and practices were to: a. Prevent, detect, investigate and control infections in the facility. b. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the public. c. Establish guidelines for implementing isolation precautions, including Standard and Transmission-Based precautions: d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions. e. Maintain records of incidents and corrective actions related to infections; and f. Provide guidelines for the safe cleaning and reprocessing or reusable resident-care equipment. However, the policy lacked specific provisions for consistent tracking, analysis, and response to respiratory infections, including COVID-19, Influenza, and RSV. No additional infection control policies were provided upon request during the survey. During an interview on January 28, 2025, at 12:00 PM, the Infection Preventionist and Director of Nursing confirmed that the policy provided was the facility's only infection control policy and were unaware of any additional policies. A review of the facility's infection control tracking logs revealed the system in place did not provide evidence of a functional method for monitoring and investigating infections. The logs did not document trends, clusters, changes in prevalent organisms, or increases in infection rates in a timely manner. There was no documentation indicating that residents with upper respiratory symptoms were tested for viral illnesses such as COVID-19, Influenza, or RSV. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include metabolic encephalopathy (a change in how the brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and diabetes. A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 10, 2025, revealed that Resident 1 had a BIMS score (a test used to get a quick snapshot of how well you are functioning cognitively at the moment, a score of 13 to 15, cognitively intact) of 15. The resident was noted to be cognitively intact. A review of nursing documentation dated December 27, 2024, at 2 A.M. revealed Resident 1 exhibited symptoms of an upper respiratory infection, coughing. The resident was administered cough medication and evaluated via telemedicine but was not tested for any respiratory virus. On December 28, 2024 at 8:15 A.M., the resident was experiencing shortness of breath and the resident's oxygen saturation level dropped to 84% (normal 95% to 100%) on 4 liters of oxygen. , Documentation revealed the residents needs could not be met at the facility and the resident was transferred to the hospital, and tested positive for RSV (Respiratory Syncytial Virus, a common respiratory virus that infects the nose, throat, and lungs. RSV symptoms make it difficult to distinguish it from the common cold or other respiratory viruses like the flu or COVID-19). There was no documented evidence the facility assessed, tested , or implemented isolation precautions for the resident prior to hospitalization . Interviews conducted on January 28, 2025, with Employee 1 (LPN), Employee 2 (LPN), and Employee 3 (RN Supervisor) confirmed that while COVID-19 testing supplies were available, testing was not routinely conducted for residents exhibiting symptoms unless indicated by the facility's COVID-19 assessment form. Employees confirmed that the facility no longer implemented isolation precautions for COVID-19, and testing for other respiratory illnesses such as RSV or Influenza was not part of the routine protocol. A review of infection control data revealed the following infections were tracked as noted: December 2024: 5 urinary tract infections (UTI), 1 eye infections, 1 ear infection, 2 skin infections and 8 upper respiratory infections (URI). January 2025: 6 UTI, 2 ear infection, 19 upper respiratory infection and 3 skin infection, 4 eye infections. The facility tracking logs were noted to be comprehensive, noting all the infections on each monthly log. The logs did not indicate if the residents with noted upper respiratory symptoms were tested for COVID-19, Influenza or RSV (viral illnesses). Further review of the facility's infection control logs revealed the data collected was incomplete and did not include resident room locations, infectious organisms, or treatments provided. There was no documented analysis of infection trends, interventions, or follow-up measures to prevent the spread of infections. Additionally, there was no documentation of infection resolution dates, complete culture information, or whether isolation precautions were implemented when necessary. During an interview on January 28, 2025, at approximately 1:00 PM, the Infection Preventionist confirmed that the facility's tracking system was incomplete and did not support routine, ongoing surveillance to identify healthcare-associated infections, communicable disease outbreaks, or infection risks. She further stated that she had been using corporate forms that did not allow for the inclusion of detailed infection data. The facility failed to develop and implement a comprehensive infection control program, including effective tracking, monitoring, and response measures. This failure had the potential to place residents at increased risk for infection transmission and prevent the implementation of appropriate infection prevention practices. 28 Pa Code 211.10 (c)(d) Resident Care Policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1)(e)(1) Management

Based on a review of nurse staffing, clinical records, grievances lodged with the facility and the minutes from Residents Council meetings and staff, resident and family interviews, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality of care to residents, and in accordance with each resident's plan of care, to meet individualized needs and promote the resident's health and well-being. Findings included: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care. Resident Council Meeting minutes dated May 7, 2024, revealed that the DON explained to residents that there will be a nurse aide class beginning next month and that three new nurse aides were hired to increase facility staffing. During an interview on May 28, 2024, at 12:10 PM, Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for staff assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond promptly. Resident 88 further explained that the facility staff are nice and work hard, but when there is only one person assigned to her hall, then that person can't help everyone. During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that he is upset that there is not enough staff working in the facility to properly care for his family member. The family member stated that until hospice services began for Resident 88 on March 25, 2024, the facility staff would often leave her in bed until 11:00 AM or later. He explained that she was in bed until 2:00 PM on a few occasions. The family member explained that now that staff from the hospice agency are coming daily Monday through Friday, the hospice staff get her out of bed each morning. He stated that the lack of care is likely because of the low nurse staffing in the facility. The family member stated that he believes his mother developed a pressure injury because of the lack of care by the facility. He explained that she never had bed sores in the past, but she had been lying in bed for hours at the facility. During an interview on May 28, 2024, at 12:30 PM, Resident 298 stated that she had been in the facility for only a few days. She explained that sometimes she is in pain and needs the staff's assistance. Resident 298 stated that she has stopped ringing the call bell because it takes at least 20 minutes for staff to respond to her request for assistance. During a resident group interview with alert and oriented residents, on May 29, 2024, at 10:00 AM, all residents in attendance indicated that the facility doesn't have enough staff to take care of the residents and meet their needs timely. The residents explained that when the facility is short on staff, residents experience long waits for care and assistance. The residents stated that this has been discussed at resident group meetings with no resolution to date. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 23 stated that there is often only one nurse aide working on her hall. She explained that she had recently waited over an hour for staff to provide her care after she rings her call bell. She explained that she is frustrated and angry that no one in the facility addresses this issue. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 30 stated that she has recently waited one hour for staff assistance and has waited as long as two hours within the last two weeks. She explained that sometimes there is only one staff member assigned to her hall, causing long waits for care. Resident 30 explained that she and her husband are both dependent on staff for their care. She indicated that she attempts to help her husband because she does not like to see him waiting for assistance, even though she knows it is not safe for her to do so. During the resident group interview on May 29, 2024, at 10:00 AM, Resident 64 stated that he has soiled himself because the staff response is longer than his body is able to wait. During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and DON verified that all residents at the facility should be treated with dignity and respect, including timely staff responses to residents' requests for assistance. A clinical record review revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and acute kidney failure (kidneys are suddenly not able to filter waste products from the blood). A baseline care plan dated February 19, 2024, indicated that Resident 88 has the potential for altered skin integrity, with a goal to prevent a skin breakdown or injury. The plan included an intervention to turn the resident every two hours and as needed, provide incontinence care as needed, apply preventative skin care each shift and as needed, apply barrier incontinence cream each shift and as needed, and report any skin breakdown to the charge nurse. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 21, 2024, revealed that Resident 88 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Resident 88 was dependent on staff to roll from lying on the back to the left and right sides, to move from a sitting position to lying on the bed, to stand from a sitting position, to transfer to and from a bed to a chair, and to get in and out of a tub or shower. A Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated February 26, 2024, indicated that Resident 88 was assessed and found to be at risk of developing pressure injuries. Braden Scale for Predicting Pressure Sore {Ulcer} Risk dated March 11, 2024, indicated that Resident 88 was assessed and found to be not at risk of developing pressure injuries. The assessment indicated that Resident 88 was rarely moist (skin is usually dry) and walked occasionally (walks during the day, but for very short distances). However, a review of the survey documentation reports dated February 2024 and March 2024 revealed that from February 19, 2024, through March 11, 2024, Resident 88 walked on only four out of 66 shifts and was found to be incontinent of urine 26 times from February 19, 2024, through March 11, 2024. A documentation survey report for March 2024 indicated that staff did not turn and reposition Resident 88 every two hours as indicated in her baseline care plan. The report indicated that turning and repositioning began on March 18, 2024, the date the resident was first assessed to have a pressure injury. The medical record failed to indicate if staff turned or repositioned the resident every two hours prior to the resident developing a pressure injury on March 18, 2024. A pressure ulcer wound round document dated March 18, 2024, revealed that the resident was assessed to have an unstageable pressure ulcer wound on her coccyx measuring 3.0 cm x 2.0 cm x 0.2 cm. The assessment indicated that an unstageable pressure injury is full-thickness tissue loss in which the base of the ulcer is covered by slough (dead skin tissue that is yellow, tan gray, green, or brown) and/or eschar (dead tissue that is tan, brown, or black) in the wound bed. The assessment further noted that the wound was not present on admission. The wound bed was observed to have a yellow slough. The wound edges were rolled. The assessment indicated that the wound had a small amount of serous drainage. Furthermore, the assessment indicated that the wound began as two scratch-like areas that combined and opened the coccyx area. A physician's order for Resident 88 to be admitted to Hospice Services related to a diagnosis of heart failure dated March 25, 2024. During an interview on May 28, 2024, at 12:10 PM, Resident 88 was not able to recall staff turning or repositioning her during her first month of admission. Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond. During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that Resident 88 was not being turned or repositioned by staff regularly from the time of admission until the development of her pressure injury. He explained that he was upset that there were not enough facility staff to properly care for his family member. The family member stated that before hospice services began providing care to Resident 88 on March 25, 2024, the facility would often leave her in bed until 11:00 AM or later. The family member explained that now, hospice services are coming daily, Monday through Friday, and the hospice staff get her out of bed each morning. A clinical record review revealed no documentation indicating what time of day Resident 88 was assisted out of bed each morning from her admission on February 19, 2024, until the assessment of an unstageable pressure ulcer wound on her coccyx on March 18, 2024. During an observation on May 30, 2024, at 1:50 PM, the wound was measured at 1.5 cm x 1.0 cm x 0.8 cm. The wound was observed with edges intact, no odor, and no drainage noted. The wound dressing was clean, with no color noted. The resident indicated that she was not experiencing pain related to her injury. During an interview on May 31, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents receive care consistent with professional standards of practice to prevent pressure injuries and ensure pressure injuries do not develop. The DON or NHA were unable to provide evidence that Resident 88 was turned or repositioned as indicated in her baseline plan of care to prevent the development of pressure injuries. A review of the clinical record of Resident 75 revealed admission to the facility on [DATE], with diagnoses to include reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet. A physician's order dated was March 22, 2024, for the resident to receive RNP ambulation. During interview with the alert and oriented Resident 75, on May 28, 2024, at approximately 12:45 PM, the resident stated staff are not walking her. Resident 75 further stated she kept track and in the past 29 days she was walked once. The resident further stated she had told staff that she is not being ambulated as ordered and nothing was done about it. A review of Resident 75's Physical Therapy Discharge Summary dated April 29, 2024, indicated that the resident was receiving services from March 12, 2024, to April 24, 2024, and that the discharge recommendations were to receive Restorative Nursing Program (RNP, with no indication of the specifics of the restorative nursing program. A review of a facility provided document entitled Rehab Services Restorative Nursing/Functional Maintenance Referral form dated April 24, 2024, indicated that the resident was to receive ambulation, to preserve functional mobility skills. Instructions indicated RNP with a restorative nursing assistant (RNA) for ambulation with a wheeled walker for up to 300 feet contact guard (CG) assist with close wheelchair (WC) follow. A physician orders dated May 23, 2024, was noted for physical therapy (PT) 5X/week for 30 days for gait training, therapeutic exercises, therapeutic activities, neuromuscular re-education. During an interview on May 29, 2024, at approximately 11:45 AM, with the Director of Therapy Services, confirmed Resident 75 should have received RNP, with a restorative nursing assistant for ambulation, from April 24, 2024, through May 23, 2024. A review of the Documentation Survey Report v2 for April 2024, and May 2024, revealed that Resident 75's RNP for ambulation was not implemented, as recommended by in the PT discharge summary, Rehab Services Restorative Nursing/Functional Maintenance Referral, and as prescribed by the physician. Interview with the Director of Nursing (DON) on May 29, 2024, at 12:45 PM failed to provide documented evidence that Resident 75 was provided with the physician prescribed RNP program. A review of the facility's staffing levels revealed that on the following dates the facility failed to provide state minimum nurse staffing of 2.87 hours of general nursing care to each resident: March 21, 2024 - 2.46 direct care nursing hours per resident March 22, 2024 - 2.39 direct care nursing hours per resident March 23, 2024 - 2.30 direct care nursing hours per resident March 24, 2024 - 2.33 direct care nursing hours per resident March 25, 2024 - 2.39 direct care nursing hours per resident March 26, 2024 - 2.51 direct care nursing hours per resident March 27, 2024 - 2.82 direct care nursing hours per resident March 31, 2024 - 2.24 direct care nursing hours per resident April 1, 2024 - 2.72 direct care nursing hours per resident April 2, 2024 - 2.64 direct care nursing hours per resident April 3, 2024 - 2.79 direct care nursing hours per resident April 4, 2024 - 2.84 direct care nursing hours per resident April 5, 2024 - 2.81 direct care nursing hours per resident April 6, 2024 - 2.55 direct care nursing hours per resident May 24, 2024 - 2.45 direct care nursing hours per resident May 25, 2024 - 2.35 direct care nursing hours per resident May 26, 2024 - 2.27 direct care nursing hours per resident May 27, 2024 - 2.65 direct care nursing hours per resident May 28, 2024 - 2.48 direct care nursing hours per resident May 29, 2024 - 2.67 direct care nursing hours per resident May 30, 2024 - 2.25 direct care nursing hours per resident An interview with the Director of Nursing (DON) on May 31, 2024, at 12: 30 p.m., confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily. Refer F550, F686, F688 28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(2)(4) Nursing services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure consistent communication between the facility and dialysis center were completed, including weights and vital signs, and failed to monitor fluid intake for residents prescribed on fluid restrictions for two residents out of 23 residents sampled (Residents 76 and 54). Findings include: A review of a facility policy entitled Coordination of Hemodialysis Services that was last reviewed by the facility on January 25, 2024, indicated that residents requiring an outside End Stage Renal Disease [(ESRD) is a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite] facility would have services coordinated by the facility and that there would be communication between the facility and ESRD facility regarding the resident. The Dialysis Communication form would be initiated by the facility for any resident going to an ESRD center for hemodialysis [a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean blood]. Nursing will collect and complete the information regarding the resident and send to the ESRD Center. Upon the resident's return to the facility, nursing would review the Dialysis Communication form and communicate with the resident's physician and other ancillary department as needed and implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the resident's clinical record. The facility policy entitled Fluid Restrictions that was last reviewed by the facility on January 25, 2024, indicated that the Care Planning Team will discuss the restrictions, and would be included in the care plan. The dietitian documents the allowed fluids in the medical record and provide a written breakdown of fluids to nursing staff. The attending physician will be notified of resident choice not to adhere to restrictions. A review of Resident 76's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included ESRD and required hemodialysis treatments three times per week. A physician's order was dated November 26, 2023, for dialysis treatments three times per week on Monday, Wednesday, and Friday and an order for a 1,000 cc's fluid restriction [limits the amount of daily fluid consumption to help avoid fluid overload (build-up of fluid] per day. A review of Resident 76's plan of care that was last revised on April 15, 2024, indicated that the resident required dialysis related to renal failure and would not have any signs or symptoms of complications from dialysis. Planned interventions included to communicate with dialysis facility as needed, monitor resident treatment records from dialysis center, 1,000 ml per 24-hour fluid restriction, and 600 cc's from dietary and 400 cc's from nursing. Review of Resident 76's Medication Administration Record dated January 2024 through May 31, 2024, revealed that the facility was not monitoring the total amount of fluids that the resident was consuming from meals and medications. The resident's Survey Documentation Report [an electronic record that summarizes planned resident centered tasks and care completed by nurse aides] dated January 2024 through May 31, 2024, revealed that fluid consumption was not consistently recorded. Resident 76's clinical record failed to reveal that staff were consistently and accurately recording and monitoring the physician's prescribed fluid restriction and unable to determine the actual amount of fluids consumed. The resident's plan of care failed to indicate the amount of fluids that would be provided at meals and snacks. A review of Resident 76's Dialysis Communication forms April 2024 through May 31, 2024, revealed that there were no post dialysis weights recorded. The facility failed to provide documented evidence that post dialysis/dry weights were obtained to ensure that Resident 76 medical status was monitored for potential complications post treatments. A review of Resident 54's clinical record revealed that the resident was readmitted to the facility was on January 2, 2024, with diagnoses that ESRD and receiving hemodialysis, and dementia [is the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities]. A physician's order dated January 3, 2024, was noted for dialysis treatments three times per week on Monday, Wednesday, and Friday and an order for a 1,500 cc's fluid restriction [limits the amount of daily fluid consumption to help avoid fluid overload (build-up of fluid] per day. Resident 54's plan of care that was last revised on April 23, 2024, indicated that the resident required dialysis related to renal failure and would not have any signs or symptoms of complications from dialysis. Planned interventions included to communicate with dialysis facility as needed, monitor resident treatment records from dialysis center, 1,500 ml per 24-hour fluid restriction, 260 cc's from nursing every shift. Review of Resident 54's Medication Administration Record dated January 2024 through May 31, 2024, revealed that the facility was not monitoring the total amount of fluids that the resident was consuming from meals and medications. The Survey Documentation Report dated January 2024 through May 31, 2024, revealed that fluid consumption was not consistently recorded. Resident 54's clinical record failed to reveal that staff were consistently and accurately recording and monitoring the physician's prescribed fluid restriction and unable to determine the actual amount of fluids consumed. The resident's plan of care failed to indicate the amount of fluids that would be provided at meals and snacks. A review of Resident 54's Dialysis Communication forms April 2024 through May 31, 2024, revealed that there were no post dialysis weights recorded. The facility failed to provide documented evidence that post dialysis/dry weights were obtained to ensure that Resident 54's medical status was monitored for potential complications post treatments. During an interview with Employee 1, Registered Nurse Supervisor, on May 29, 2024, at 10:35 a.m., revealed that each dialysis resident had a Dialysis Communication form that should have a recorded pre and post dialysis weight. Employee 1 reported that post weights for dialysis residents were not being consistently obtained at the dialysis treatment center and that facility staff didn't follow-up with the center to ensure a weight was collected and entered into the resident's clinical record for post dialysis monitoring. The facility was unable to provide documented evidence that the facility ensured that Resident 76's and Resident 54's physician prescribed fluid restriction or fluid intakes were accurately recorded or monitored. Interview with the Director of Nursing (DON) on May 31, 2024, at 10:30 a.m., confirmed that the facility failed to accurately document fluid intakes for residents ordered on fluid restrictions and failed to provide documented evidence post dialysis weights were obtained, recorded, and monitored for Residents 76 and 54. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on a review of grievances filed with the facility and minutes from resident group meetings, and resident, family, and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two out of the 23 residents sampled (Residents 88 and 298) and three out of 10 residents interviewed during a group interview (Residents 23, 30, and 64). Findings include: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care. Resident Council Meeting minutes dated May 7, 2024, revealed that the DON explained to residents that there will be a nurse aide class beginning next month and that three new nurse aides were hired to increase facility staffing. During an interview on May 28, 2024, at 12:10 PM, Resident 88 stated that she sometimes waits 30 minutes for staff to respond when she rings her call bell for staff assistance. The resident explained that the wait time is longer on the weekends. Resident 88 stated that she ends up soiling herself when staff are not able to respond promptly. Resident 88 further explained that the facility staff are nice and work hard, but when there is only one person assigned to her hall, then that person can't help everyone. During an interview on May 28, 2024, at 12:15 PM, Resident 88's family member explained that he is upset that there is not enough staff working in the facility to properly care for his family member. The family member stated that until hospice services began for Resident 88 on March 25, 2024, the facility staff would often leave her in bed until 11:00 AM or later. He explained that she was in bed until 2:00 PM on a few occasions. The family member explained that now that staff from the hospice agency are coming daily Monday through Friday, the hospice staff get her out of bed each morning. He stated that the lack of care is likely because of the low nurse staffing in the facility. The family member stated that he believes his mother developed a pressure injury because of the lack of care by the facility. He explained that she never had bed sores in the past, but she had been lying in bed for hours at the facility. During an interview on May 28, 2024, at 12:30 PM, Resident 298 stated that she had been in the facility for only a few days. She explained that sometimes she is in pain and needs the staff's assistance. Resident 298 stated that she has stopped ringing the call bell because it takes at least 20 minutes for staff to respond to her request for assistance. During a resident group interview with alert and oriented residents, on May 29, 2024, at 10:00 AM, all residents in attendance indicated that the facility doesn't have enough staff to take care of the residents and meet their needs timely. The residents explained that when the facility is short on staff, residents experience long waits for care and assistance. The residents stated that this has been discussed at resident group meetings with no resolution to date. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 23 stated that there is often only one nurse aide working on her hall. She explained that she had recently waited over an hour for staff to provide her care after she rings her call bell. She explained that she is frustrated and angry that no one in the facility addresses this issue. During a resident group interview on May 29, 2024, at 10:00 AM, Resident 30 stated that she has recently waited one hour for staff assistance and has waited as long as two hours within the last two weeks. She explained that sometimes there is only one staff member assigned to her hall, causing long waits for care. Resident 30 explained that she and her husband are both dependent on staff for their care. She indicated that she attempts to help her husband because she does not like to see him waiting for assistance, even though she knows it is not safe for her to do so. During the resident group interview on May 29, 2024, at 10:00 AM, Resident 64 stated that he has soiled himself because the staff response is longer than his body is able to wait. During an interview on May 31, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and DON verified that all residents at the facility should be treated with dignity and respect, including timely staff responses to residents' requests for assistance. Refer F686 and F725 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of clinical records, facility provided documentation, select investigative reports and staff interview, it was determined that the facility failed to consistently provide necessary assistance devices and/or utilize safe technique while performing activities of daily living (showering/bathing) to prevent a fall resulting in serious injuries, a fractured left femur and sacrum, for one out of 4 sampled residents (Resident CR 2). Findings include: A review of the clinical record revealed that Resident CR 2 was admitted to the facility on [DATE], with diagnoses of muscle weakness, [CONDITION(S)] (a disorder of the central nervous system that affects movement, often including tremors), protein-calorie malnutrition, anxiety, dysphagia (difficulty swallowing foods or liquids), right and left knee contracture, Alzheimer's (a progressive disease that destroys memory and other mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning), lack of coordination, and abnormal posture. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 13, 2021, revealed that Resident CR 2 was severely cognitively impaired, and was totally dependent on staff with activities of daily living including bed mobility, dressing, transfer, toileting, eating, personal hygiene, and bathing. In addition, the resident had functional limitations (impairment) in range of motion (ROM) of both the left and right, upper and lower extremities. A review of the resident's care plan (a tool, information, used by staff to guide a resident's care) for decline in activities of daily living (ADLs) initially dated June 1, 2021, revealed that the resident was totally dependent on two staff for bathing/showers and to provide a stretcher shower twice weekly and as necessary. A nursing progress note dated March 22, 2022, at 10:20 AM, revealed that the resident was in the common shower room, lying on the floor, on her left side. Her left side of head was touching, lying on the bottom of shower chair. Scant amount of blood was noted from a scrape of the left side of head, near eyebrow, measuring 0.5 cm x 0.5 cm. The resident's arms and legs were assessed for abnormality due to contractures, no abnormalities noted. Arms and legs equal in length, no non-verbal signs of pain noted. Temp -98.2, Pulse -87, Resp -18, BP -131/85, SPO2 -91% RA. Pupils equal, round and briskly reactive to light. No other injuries noted. Family, and physician aware, no new orders noted. Neurowatch initiated for continued monitoring. A review of facility provided incident investigation, fall investigation form, and other facility provided documentation indicated that on March 22, 2022, at approximately 10:05 AM the resident incurred a fall in the shower room and that the fall was witnessed by staff, while in the process of bathing the resident. According to the fall reports and investigation, a nurse aide rolled the resident on the shower bed and the resident fell off the shower bed. The root cause analysis indicated the employee did not use an assist of two staff members to shower. However, during the investigation it was determined that the resident was reportedly inaccurately care planned as an assist of two staff members for bathing, and according to the facility the resident should have been only an assist of 1 staff member, but to ensure that the rails were up on the shower bed. Review of Employee 1 (Certified Nursing Assistant - CNA) witness statement dated March 22, 2021, (incorrectly dated 2021) stated I then moved resident from her room to the spa on upper East. I then began to shower resident, I made sure all my lock where (sic) on the shower bed. I do not know that we had to have 2 staff to give resident a shower on shower bed. After showering resident I began to dry her. I round (sic) resident left side 1st to dry and I round (sic) her to the right side to put towel under resident to dry her and she round (sic) out on the right side of bed. I turn to catch the resident but was unable. It could not be specifically determined by review of the facility's investigation report or Employee 1's witness statement if the employee had rolled the resident away from her (and not towards her body to safely support the resident) place the towel under the resident. The technique of rolling the resident away from the aide, with no other staff member on the opposite side and no rail up on the shower stretcher, while providing the resident's care increased the risk of the resident rolling off the shower bed. A Medication Administration Note, dated March 22, 2022, at 10:20 AM, indicated that the resident had facial grimacing and on March 23, 2022, at 1:30 PM, complained of left shoulder pain. A review of the Medication Administration Record (MAR) for March 2022, revealed Acetaminophen (Tylenol) 650 mg was administered to the resident on March 22, 2022, at 12:17 PM, and on March 23, 2022, at 1:30 PM, for pain. A nursing progress note dated March 23, 2022, at 2:51 PM, indicated that the resident had pain/discomfort in left shoulder and left hip areas. The resident's vital signs were stable. A call was placed to the physician and a new order was noted to send the resident to Hospital ER for an evaluation. The resident's family was aware. Nursing progress notes dated March 24, 2022, at 2:08 AM, indicated that the resident was resident was admitted to the hospital with diagnoses of a Left femur fracture and a Sacral fracture. A review of hospital documentation, a Computed Tomography (CT) scan, (a diagnostic test) of the chest abdomen and pelvis with contrast, dated March 23, 2022, revealed that Resident CR 2 had a displaced comminuted fracture (a break or splinter of the bone into more than two fragments) of the left femur (leg bone) shaft and subtle, possible nondisplaced fractures through bilateral sacral ala. During an interview on April 12, 2022, at approximately 11:20 AM, the Director of Nursing (DON) confirmed that the resident's care plan revealed the resident was totally dependent for showering/bathing, and required two staff members, and that only one staff member had provided the resident's shower. The DON confirmed that the resident's care plan, as written and in effect at the time of the fall, was not followed. During the facility's investigation it was determined that the resident had been inaccurately care planned as an assist of 2 staff members for bathing, but should have been an assist of one staff member and that the staff member was to ensure the rails are up on the shower bed. This deficiency is cited as past non-compliance. The facility's corrective action plan was that all current residents were reviewed by the interdisciplinary team (IDT) to ensure that the care plan accurately reflected for the amount of assistance needed in bathing - not including the transfer, but the act of bathing. All care plans were reviewed and updated as necessary. Nursing staff were educated related to utilizing the Kardex, bathing a resident on utilizing the shower bed. A quality review will take place 5 X a week for 8 weeks of ensuring that the care plan is being followed for ADLs and bathing will be reviewed by the DON or designee. All information will be reviewed by the Quality Assurance Performance Improvement (QAPI) team monthly, and Quality Assurance (QA) reviews schedules will be revised as necessary. The facility's immediate corrective action plan was completed April 5, 2022. 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide adequate staff supervision and assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls resulting in a serious injury, a [CONDITION(S)], for one of 4 sampled (Residents CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE]. The resident had diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated October 8, 2021, revealed that the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility and transferring, and required supervision of one staff member when moving about on the nursing unit. A review of the resident's care plan for the problem of risk for falls revealed an intervention initially dated July 16, 2021, and revised July 29, 2021, indicating that the resident required an electronic safety alarm on the bed and chair and a motion detector alarm on the floor at the foot of the resident's bed. The care plan noted that staff were to check the alarms every shift for placement and functioning. An intervention dated August 23, 2021, indicated that the resident was to be ambulated 100 feet daily with the assistance of one person to decrease the resident's attempts of self-ambulation. A review of a fall risk evaluation of the resident dated July 16, 2021, revealed that the resident was assessed at a high risk for falling. A review of progress notes dated September 13, 2021, at 11:52 PM indicated the resident was found lying on his left side, on the floor of the east wing hallway, with his wheelchair behind him. An incident report revealed that on September 13, 2021, at 7:00 PM Resident CR1 was found lying on his left side with his alarm sounding in front of his wheelchair. It was noted that the fall was unwitnessed. A witness statement from Employee 1 RN (registered nurse) dated September 13, 2021, revealed that the resident was in his wheelchair propelling himself on the nursing unit. The employee stated the resident was in a bad mood and insisting on going home. Employee 1 stated that the resident was near his room, when he stood up and the chair alarm sounded as the resident attempted to walk and he fell to the floor. Following this fall, the resident's care plan for fall risk was updated to include a new intervention for the resident to have medication review. A review of a nursing note dated September 27, 2021, at 10:27 AM revealed that the resident was in the dining room when he stood up from his wheelchair attempting to ambulate. The alarm sounded. The resident attempted to sit back down and missed the wheelchair and sat on the floor. An incident report dated September 27, 2021, at 10:15 AM revealed that Resident CR1 stood up from his wheelchair and attempted to ambulate. The resident went to sit back down in his wheelchair, missed the wheelchair, and fell to the floor. A review of Employee 2's (RN) witness statement dated September 27, 2021, revealed that the employee observed the resident stand up in the dining room and attempted to ambulate. Before the employee could reach the resident, the resident lost his balance and sat on the floor. An incident report revealed that on September 27, 2021, at 7:10 PM the resident had been seated in his wheelchair near the nourishment room door when he stood up, lost his balance, and fell to the floor. A witness statement from Employee 1, RN, dated September 27, 2021, revealed that the resident was sitting in front of the nourishment room when he stood up from his wheelchair attempting to ambulate and fell to the floor. Employee 1 stated that the resident's wheelchair seems to be an issue because resident slides off the wheelchair when he attempts to reposition. There was no documentation in the resident's clinical record that the resident fell again on September 27, 2021, at 7:10 PM as noted on the incident report. There was no documented evidence that the facility addressed the issue identified by Employee 1 regarding the concern of the resident slipping out of his wheelchair when he repositions himself in the chair. After the fall on September 27, 2021, the resident's care plan for fall risk was updated September 28, 2021, for staff to offer a nap after breakfast and supper and an intervention for staff to check the resident every 15 minutes. A nurse's note dated September 29, 2021, at 10:36 AM revealed that staff were called to the resident's room to assess Resident CR1. The resident was found on the floor in front of his bed. The resident had a 2 cm (centimeter) x 1 cm laceration (cut) to the back of his head. An incident report dated September 29, 2021, at 8:45 AM revealed that the resident was found in his room sitting on his buttocks in front of his bed. The resident obtained a 2 cm x 1cm laceration to the back of his head. A review of Employee 3's (nurse aide) witness statement dated September 29, 2021, revealed that the employee was walking down the hall when she noticed staff in the resident's room trying to get him off the floor. The employee stated the resident frequently tries to get out of bed or into bed by himself. A review of the resident's care plan for fall risk revealed a new intervention added September 29, 2021, for a scoop mattress to the resident's bed. A review of the tasks completed by staff for Resident CR1 during September 2021 revealed that staff failed to ambulate the resident 100 feet daily to prevent self-ambulation attempts on 10 occassions during the month. Staff failed to check the motion detector at the end of the resident's bed for functioning on eight occassions and on nine occassions there was no evidence that the electronic safety alarm was in place on the resident's bed. A review of a nursing note dated December 3, 2021, at 11:40 PM revealed at 9:30 PM that the resident was found on the floor in the west hallway nursing unit. An incident report dated December 3, 2021, at 9:30 PM revealed that the resident was found lying on the floor, outside another resident's room. The resident's wheelchair was nearby, and this was an unwitnessed fall. A review of Employee 4 LPN (license practical nurse) witness statement dated December 3, 2021, revealed that staff notified Employee 4 that the resident was lying on the floor in the hallway. The employee stated that she reminded the resident not to get out of chair without assistance. There was no documented evidence that staff had been conducting every 15 minute checks of the residents as noted in the resident's care plan as of September 27, 2021. A review of the resident's care plan for fall risk revealed a new intervention added December 3, 2021, for the resident to be offered an earlier bedtime. A review of a nursing note dated December 9, 2021, at 9:40 PM revealed that staff heard an alarm sounding in the back hallway. The resident was found on the floor in front of his wheelchair. Nursing noted that the resident had been offered the opportunity to go back to bed prior to the fall, but the resident declined. The incident report dated December 9, 2021, at 9:15 PM revealed Resident CR1 had an unwitnessed fall and was found on the floor in front of his wheelchair in the back hallway. A review of Employee 5's (nurse aide), witness statement dated December 9, 2021, revealed that Employee 5 provided care to the resident and offered to assist the resident to bed at 8:30 PM. The employee stated that the resident refused to go to bed and she placed the resident back into his wheelchair. A review of the resident's care plan for fall risk revealed the plan of care was not revised and updated after the resident fell on [DATE]. A nursing note dated December 18, 2021, at 9:36 PM revealed that at 7:05 PM the resident was found lying on the floor in the bathroom in his room. The resident was complaining of right hip pain at that time. The physician was notified and the facility received an order to transfer the resident to the hospital for further evaluation. An incident report dated December 18, 2021, at 7:05 PM revealed the resident had an unwitnessed fall and was found lying on the floor in his bathroom crying out for help. The report noted that the {electronic safety} alarm was not on, or sounding, at the time of the fall. A review of Employee 6's (nurse aide) witness statement dated December 18, 2021, revealed that Resident CR1's family reported to Employee 6 that they had helped the resident back to bed for a nap and Employee 6 was aware that the resident was in bed. Employee 6 indicated that at that time that she checked to make sure the alarms (electronic alarm on the bed and sensor alarm at the foot of the bed) were in place and functioning after being notified by the resident's family that the resident was in bed. The employee stated she notified Employee 7, nurse aide, that the resident was in bed before she left the facility for the day. A review of Employee 7's (nurse aide) witness statement dated December 18, 2021, revealed that Employee 7 worked on the west wing nursing unit from 3:30 PM to 11:30 PM. The employee stated that she checked on the resident between 4:00 PM and 4:30 PM and he was still asleep. The employee stated that the resident woke up and ate a half of sandwich and went back to sleep. Employee 7 stated that she went in the resident's room at 6:45 PM to wake the resident up. Employee 7 indicated that employee went to go get a wheelchair and when she returned to the resident's room, she was told that the resident fell in the bathroom. The employee did not indicate that she checked the resident's bed alarms for placement and functioning from the time she came on shift at 3:30 PM until the resident fell at 7:05 PM. A review of an x-ray report dated December 18, 2021, revealed that Resident CR1 had sustained a right femoral neck fracture (broken hip) with angulation and superior migration of the distal fracture fragment (the bones were displaced, and the bone fragments were overlapping each other) as a result of the fall. A review of 15 minute check documentation for the month of December 2021 revealed that staff were not consistently implementing this intervention planned to prevent resident falls. A review of the tasks completed by staff for the resident during December 2021 through December 18, 2021, revealed that staff failed to ambulate the resident to prevent self-ambulation daily on five occassions, the resident's motion detector at the end of the bed was not checked for functioning on four occassions and electronic Sensitec alarm was not noted as in place on four occassions, including on the day the resident fell on [DATE]. The resident was identified at risk for falls with known unsafe behaviors of unassisted attempts to ambulate and transfer from the bed and wheelchair resulting in repeated falls. The facility failed to demonstrate the consistent implementation of interventions planned to prevent falls and failed to provide the resident with timely and necessary supervision, at the level and frequency required, to prevent a fall with serious injury, a [CONDITION(S)]. An interview with the Nursing Home Administrator on January 25, 2022, at approximately 1:30 PM confirmed that the facility failed to provide effective individualized safety interventions and sufficient and timely staff supervision and assistance to Resident CR1 to prevent repeated falls and a hip fracture. 28 Pa. Code 211.11(d) Resident care plan 28 Pa Code 211.12(a)(d)(5) Nursing services 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(3) Nursing services

Based on a review of clinical records, select incident reports and clinical documentation and staff interview it was determined that the facility failed to provide sufficient staff supervision and effective safety interventions to prevent a fall with head injury (new collection of blood on the brain's surface) for one resident identified at risk for falls and with a recent history of traumatic head injury out of two reviewed residents incurring falls. (Resident 294) Findings include: A review of Resident 294's clinical record indicated he was admitted to the facility on (MONTH) 6, (YEAR), with diagnoses, which included traumatic subdural hematoma (blood collects between the layers of tissue that surround the brain as blood accumulates, pressure on the brain increases), which required surgical evacuation (a left frontoparietal craniotomy). The resident also had a past medical history of [REDACTED]. The resident was noted to have a history of [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). According to the resident's admission MDS assessment (Minimum Data Set assessment-a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 13, (YEAR), the resident was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident required extensive staff assistance of two people for bed mobility, dressing, toilet use, bathing, eating, hygiene and was totally dependent for transfers with two persons. The resident was noted as always incontinent of bowel and bladder. Upon the resident's admission (MONTH) 6, (YEAR), a fall safe screening was conducted, which revealed that the resident was at risks for falls. The facility planned for the use of a low bed and safety alarms to be placed on his wheelchair and on his bed (alarms alert staff by a loud sound when the resident stands up from the wheelchair or tries to exit the bed) The resident was also receiving the anticoagulant drug, [MEDICATION NAME] (a drug that increases bleeding), according to physician orders [REDACTED]. An occupational therapy evaluation dated (MONTH) 7, (YEAR), indicated that the resident had right upper arm and lower leg impairment, poor sitting balance and was unable to stand. The resident presented with moderate to severe coordination impairments as a result of his past fall and [MEDICAL CONDITION]. On (MONTH) 15, (YEAR), a physician order [REDACTED]. from falling between the foot rests of the wheelchair). The resident also had a high back wheelchair adapted with foam wheelchair cushion seat, comfy back cushion and lateral head support. A review of a facility fall investigation report dated (MONTH) 18, (YEAR), at 4:00 PM indicated that the resident was observed lying on the floor on his right side in front of his wheelchair near the east wing nursing station. The brakes of his wheelchair were in the locked position. However, it was determined that the resident's wheelchair alarm was not present on his wheelchair to alert staff of his unassisted attempt to get out of the chair. The resident sustained [REDACTED]. The resident's pupils were sluggish (sluggish pupillary response refers to an abnormally slow response of the pupil (the round black part of the eye) to constrict when stimulated with light or expand when exposed to a reduction of light, which can be indicative of a [MEDICAL CONDITION]) when reacting to light. His speech was garbled at the time of observation. The resident was sent to the emergency room for evaluation on (MONTH) 18, (YEAR). A CT scan (computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body, providing more detailed information than plain X-rays) report from the hospital dated (MONTH) 18, (YEAR), at 4:41 PM indicated that the resident had a new subdural collection overlying the right frontal lobe from the prior study (2/20/18) measuring 6 mm in maximum thickness. The impression noted on the current hospital reports dated (MONTH) 18, (YEAR), was that the resident had a new subdural collection overlying the right frontal lobe from the prior study (dated 2/20/18). The clinical impression was that the resident presented a medium-sized subacute, traumatic right subdural hematoma; unknown if loss of consciousness had occurred; major closed head injury. The resident was admitted to the hospital's intensive care unit for critical care and treatment of [REDACTED]. The resident remained hospitalized until (MONTH) 26, (YEAR), and was subsequently admitted to another long term care skilled nursing facility. Further review of the facility's accident report indicated Employee 6, a 3:00 PM to 11:00 PM nurse aide, stated Resident 294 was changed by the dayshift aides and was left up (out of bed) to eat dinner. The resident was placed near the nurse's station so he could be supervised. Employee 6 stated that the 3:00 PM to 11:00 PM nurse aides did not provide him any care prior to his fall. Employee 6 went to help another Nurse Aide at approximately 4:00 PM and when she found Employee 7, a Nurse Aide, she was kneeling next to the resident. Employee 6 was told that the resident tried standing up from his wheelchair. Employee 7 confirmed that the resident's wheelchair alarm was not placed on the resident at the time of the fall. A statement from the dayshift nurse aide, Employee 8, indicated that she was assigned to the resident. Employee 8 noted that the resident was tired and sleeping most of the morning (March 18, (YEAR)). Employee 8 stated they were going to leave him in bed, but his girlfriend called and she wanted him out of bed. The resident was given a shower and placed in his wheelchair. He was placed in the dining room for lunch in his high back wheelchair, but because of an increase in restlessness he was placed at the nurse's station for supervision. Employee 8 stated it was a busy day and she could not recall if she placed his wheelchair alarm on his chair. A statement by Resident 63, who witnessed Resident 294's fall stated he saw the resident stand up and try to go for a walk and he fell over, like he lost his balance. He didn't even make it to a full stand up, half way, three quarters at the most and he bent right over forward like he lost his balance. A review of facility documentation for (MONTH) 18, (YEAR), indicated that the resident's bed alarm was functioning and in place on each of the three shifts, but according to employee statements and the facility's incident report the alarm had not been in place at the time of the resident's fall. Interview with the Director of Nursing (DON) on (MONTH) 20, (YEAR), at 2:30 PM confirmed that the facility failed to apply the wheelchair alarm as planned to alert staff of unsafe transfers as indicated in the resident's plan of care. The DON further stated that the alarm may not have been effective if it had been in place and sounded because staff was not present near the nurse's station to respond to the alarm. The DON was unable to provide evidence that adequate safety measures were in place, including sufficient staff supervision, to prevent this fall, with head injury, which compromised the resident's condition, for a resident at risk for falls, increased bleeding and a recent history of traumatic head injury. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 4/21/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 5/12/17 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 3/1/18, 5/12/17, 3/20/17, 4/21/16

Based on review of clinical records, select facility policy and resident accident/incident reports, observation and resident and staff interview, it was determined that the facility failed to accurately assess the use of devices that restrict freedom of movement such as physical restraints for one resident (Resident 35) out of 20 sampled. Findings include: The facility Restraint Assessment Implementation Policy, last reviewed by the facility on January 20, 2011, indicated that a restraint was any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual can not easily remove which restricts freedom of movement or normal access to one's body. A restraint assessment will be performed by nursing to assess the physical, mental, and contributing factors, which would indicate the need for a restraint. The PT/OT (Physical/Occupational Therapy) department will review the nursing findings and would document (therapy) recommendations. Clinical record review revealed that Resident R35 had [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated February 25, 2011, indicated that the resident was severely impaired cognitively and utilized no physical restraints. A significant change Minimum Data Set assessment (an assessment indicating either an improvement or decline in a resident's condition) dated, April 14, 2011, also indicated that the resident had no physical restraints. Observation of the resident on May 25, 2011, at 11:50 a.m., revealed that the resident was seated in a wheelchair with an alarmed fastened clip (seat) belt (a seat belt that alarms when released). During an interview with the resident at this time, the resident stated that the alarmed clip belt was used to keep her in her chair so that she, "could not run away." The resident stated that she could not open the alarmed clip belt. A second observation of the resident on May 26, 2011, at 11:00 a.m., revealed that the resident was seated in a wheelchair with the alarmed clip belt fastened. Employee 7 (a nurse aide) made a request to the resident to unfasten the device. Again, the resident stated that she was not able to open the clip belt. Review of the resident's Restraint assessment dated , January 21, 2010, indicated that the resident was alert to person only, had no safety awareness, and displayed restlessness and anxiousness. The alarmed clip belt was identified as a physical restraint at this time. Also noted at this time was an interdisciplinary team recommendation to place the resident's bed against the wall (the left side of the bed). It was noted that the resident had a history of [REDACTED]. The interdisciplinary team determined that the bed against the wall was not a restraint because the resident was freely able to exit on the right side of the bed at will. Review of the clinical record revealed that the resident also had a physician order [REDACTED]. Further review of the clinical record revealed no documented evidence that the application of the pool noodles to both sides of the resident's mattress were assessed as limiting the resident's freedom of movement with the potential to physically restrain the resident. The restraint assessment notes dated November 10, 2010, December 21, 2010, January 26, 2011, February 28, 2011, March 4, 2011, April 11, 2011, and May 2, 2011, indicated that the resident was reassessed for the alarmed clip belt in the wheelchair due to poor safety awareness and that the resident was able to freely remove the belt. The Restraint Assessment of January 21, 2010, identified the use of the alarmed clip belt as a restraint for this resident, which was confirmed during the observation of the resident during the survey and her inability to self-release the belt on command. There was no documented evidence that detailed when and how the cognitively impaired resident became able to freely release the belt as noted in the restraint assessment notes from November 10, 2010 through May 2, 2011. Further review of the clinical record revealed there was no documented evidence that the facility had identified, prior to the survey, that the resident was no longer able to open the alarmed clip belt when requested. Interview with the Administrator on May 26, 2011, at 2:00 p.m., confirmed that there was no documented evidence that the facility had identified that the resident could not release the alarmed clip belt. Review of a nurses note dated, March 26, 2011, at 1:00 a.m., noted that the resident was found sitting on the floor at the foot of the bed. An Accident/Incident Report Form dated, March 26, 2011, noted that the pool noodles were intact on the right side of the bed and the left side of the bed was against the wall. It was noted that the resident had climbed over the footboard of the bed and sustained a 2 cm (centimeter) in length superficial skin tear to the left posterior calf. The resident complained of left hip pain and was noted to have external rotation with slight shortening of the left lower extremity. The resident was sent to the emergency room and was admitted with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on May 25, 2011, at 9:00 a.m., confirmed that the facility had not considered the danger of the resident attempting to exit from the bed via the foot of the bed, due to the left side of the bed against the wall and the pool noodles under the mattress on the right side of the bed which affected the resident's ability to exit on that side of the bed. The DON confirmed that there was no documented evidence that a thorough physical restraint assessment was completed as per facility policy for the resident to identify and evaluate the risks associated with the use of physical restraints for the resident. Refer to F323 28 Pa Code 201.18(e)(1) Management. Previously cited 5/28/09, 12/11/09, 4/16/10, 1/10/11 28 Pa. Code 211.8(d)(e)(f) Use of restraints 28 Pa. Code 211.10(a) Resident care policies. Previously cited 5/28/09, 4/16/10 28 Pa. Code 211.10(d) Resident care policies. Previously cited 4/16/10 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 4/16/10, 1/10/11