Every finding on record at Maple Farm

Based upon clinical record review, facility observation, review of facility policies, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one resident (Resident #13) out of 16 residents reviewed. Review of facility policy Enhanced Barrier Precautions, last reviewed April 23, 2025, states Enhanced Barrier Precautions will be used for those residents with chronic wounds. Review of Resident #13's wound assessment report dated May 28, 2026, finds that resident has a neuropathic ulcer (a chronic, slow healing, open sore or wound caused by nerve damage and poor circulation) on the left medial first metatarsophalangeal base (where the first toe connects to the long foot bone). Review of Resident #13's orders does not find an order for Enhanced Barrier Precautions (an infection control strategy used to prevent the spread of multi-drug-resistant organisms). Observation at Resident #13's room on June 2, 2026, at 10:02 a.m., June 3, 2026, at 1:15 p.m., and June 4, 2026, at 9:20 a.m., does not find Personal Protective Equipment or signage indicating Enhanced Barrier Precautions Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2026, at 11:30 a.m. confirms that Resident #13 is being treated for a chronic diabetic ulcer on the resident's left foot and the resident is not on Enhanced Barrier Precautions. An interview on June 4, 2026, at 12:00 p.m. with the Nursing Home Administrator confirms that the facility failed to place Resident #13 on Enhanced Barrier Precautions. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, staff interviews, and clinical record review, it was determined that the facility failed to discuss the risks/benefits and obtain consent for newly ordered antipsychotic and opioid medications for three of twelve residents records reviewed (Residents 2, 22, and 29). Findings include: Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's disease (loss of cognitive functioning such as thinking, remembering, and reasoning and interferes with a person's daily life) and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking) with psychosis (a mental health condition characterized by a loss of touch with reality). Review of Resident 2's physician orders included: Seroquel 25 milligrams (MG) give 0.5 tablet (12.5 MG) one time a day for psychosis, start date December 21, 2024, and discontinue date December 30, 2024; Seroquel 25 MG give 0.5 tablet (12.5 MG) two times a day, start date December 30, 2024, and discontinue date January 21, 2025; Seroquel 25 MG two times a day, start date January 21, 2025, discontinue date January 24, 2025 (due to hospitalization ); and Seroquel 50 MG two times a day, start date January 31, 2025. Review of clinical record on May 28, 2025, at 11:00 AM, failed to include documentation that the risk/benefit for Seroquel was reviewed with the Responsible Party or that consent was obtained. Interview with Nursing Home Administrator (NHA) on May 28, 2025, at 12:58 PM, revealed the facility does not have a consent and risk/benefit form, but they are in the process of formulating one. The facility calls the Resident Representative to inform of the new medication and discuss risks and benefits. Additional clinical record review on May 29, 2025, documented the facility form Informed Consent for Psychotropic Medication Use was completed for Resident 2 for an antipsychotic, which included review of the risks and benefits, and verbal consent from her grandson. Review of Resident 22's clinical record revealed diagnoses that included depression (feelings of severe despondency and dejection), psychosis (a mental health condition characterized by a loss of touch with reality), schizoaffective disorder (a mental health condition that is marked by a mix of hallucinations, delusions, depression and mania), anxiety (a feeling of worry, nervousness, or unease), vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), insomnia (difficulty sleeping), and hemiplegia (paralysis or severe weakness on one side of the body) on right dominant side. Review of Resident 22's physician orders included: Seroquel 25 MG give 0.5 tablet two times a day for psychosis, start date May 13, 2025; Sertraline 25 MG one time a day related to depression, start date May 13, 2025. Review of clinical record on May 28, 2025, at 10:00 AM, failed to include documentation that the risk/benefit of Seroquel and Sertraline use was reviewed with the Responsible Party and that consent was obtained. Interview with NHA on May 28, 2025, at 12:58 PM, revealed the facility does not have a consent and risk/benefit form, but they are in the process of formulating one. The facility will call the Resident Representative to inform them of the new medication and discuss risks and benefits. Additional clinical record review on May 29, 2025, documented the facility form Informed Consent for Psychotropic Medication Use was completed for Resident 22 for an antidepressant and antipsychotic, which included review of the risks and benefits, and verbal consent from his Resident Representative/ Power of Attorney. Review of Resident 29's clinical record revealed diagnoses that included psychotic disorder (a severe mental disorder characterized by a significant disconnect from reality, involving abnormal thinking, perceptions, and behavior) and vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes). Review of Resident 29's physician orders revealed the medication Seroquel 25 MG with directions of give 0.5 tablet by mouth at bedtime related to psychotic disorder with hallucinations. Review of Resident 29's clinical record revealed no documentation to support the Resident and/or Representative were informed of the risks/benefits of the use of the antipsychotic medication. An interview with the NHA on May 29, 2025, at 11:56 AM, revealed Resident 29's Representative was informed of the addition of the Seroquel, however, no discussion of the risks/benefits was found. 28 Pa. Code 201.29(j) Resident rights

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one resident's reviewed receiving a tube feeding (Resident 3). Findings include: Review of facility policy, Medication Administration, revision date June 19, 2023, read, in part, the nurse who administers the medication and/or treatment (medications, IV feedings, etc.) shall document such by initialing electronically signing the MAR (Medication Administration Record - form used to document physician's orders as well as when and how medications are administered to a resident) as soon as possible following administration. If the resident refuses medications, the nurse shall notify the physician after two consecutive refusals and document the refusal in the Medical Record. Supplementary feeding that is withheld shall be designated in the electronic system as held on the MAR or TAR. The nurse shall document the reason the supplementary feeding was not administered. Review of facility policy, Enteral Feeding and Medication Administration, revised February 3, 2023, read, in part, the container holding feeding is labeled with date and time started. The orders will include the formula name, the rate (cc/hr.) for how many hours. The orders will also include the amount of water to flush the tube with to meet the resident's hydration needs. Review of Resident 3's clinical record revealed diagnoses that included traumatic brain injury (brain dysfunction caused by an outside force), paraplegia (loss of motor and sensory functions in the lower half of the body typically affecting both legs), dysphagia (difficulty swallowing), aphasia (language disorder that affects a person's ability to communicate), anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). Observation May 27, 2025, at 11:19 AM, revealed an Isosource (a dense complete nutrition formula) supplement bag and bag of fluid/flush not labeled, or date marked. Interview on May 27, 2025, at 11:24 AM, Employee 1 (Licensed Practical Nurse) stated the aforementioned bags were put up on evening shift and are taken down on dayshift. It was also revealed that both bags should contain a sticker noting the contents and the date and time the bags were hung; it was confirmed neither bag were labeled, or date marked. Review of Resident 3's physician orders included: Isosource 1.5 tube feeding @ 60cc/hr. x 18 hours or until 1080cc total volume has infused. Water flushes 10cc/hr. take down/stop at 1:00 PM and start tube feed at 7:00 PM daily, start date May 16, 2025; Isosource 1.5 tube feeding @ 64cc/hr. x 18 hours or until 1152cc total volume has infused. Water flushes 10cc/hr. take down/stop at 1:00 PM and start tube feed at 7:00 PM daily, start date April 30, 2024, discontinued May 15, 2025; Isosource 1.5 tube feeding @ 68cc/hr. x 18 hours or until 1224cc total volume has infused. Water flushes 10cc/hr. take down/stop at 1:00 PM and start tube feed at 7:00 PM daily, start date April 4, 2025, discontinued April 30, 2025; Isosource 1.5 tube feeding @ 74cc/hr. x 18 hours or until 1332cc total volume has infused. Water flushes 10cc/hr. take down/stop at 1:00 PM and start tube feed at 7:00 PM daily, start date March 15, 2025, discontinued April 3, 2025; and Isosource 1.5 tube feeding @ 78cc/hr. x 18 hours or until 1404cc total volume has infused. Take down/stop at 1:00 PM and start tube feed at 7:00 PM daily, start date January 18, 2024, discontinued March 14, 2025. Review of Resident 3's May 2025 MAR documentation for total volume of Isosource at 2:00 PM was less than the physician ordered total volume of 1080cc on: 22nd= 825cc; 24th= 990c; 25th= 995cc; and 26th= 990cc. Review of Resident 3's April 2025 MAR documentation for total volume of Isosource at 2:00 PM was less than the physician ordered total volume of 1224cc on the 23rd = 1118cc. Review of Resident 3's March 2025 MAR documentation for total volume of Isosource at 2:00 PM was less than the physician ordered total volume of 1404cc on the 10th = 918cc, and 13th = 507cc. Progress notes failed to document rational for not infusing to total amount of Isosource per physician order for the aforementioned dates. During an interview with the Nursing Home Administrator on May 29, 2025, at 10:57 AM, it was revealed that the tube feeding bags are to be labeled with a sticker and staff have been educated. It was also revealed that the stickers fall off sometimes. During an interview with Employee 2 (Registered Nurse) on May 29, 2025, at 12:26 PM, it was revealed that the tube feeding orders were written for 18 hours or until a specific total volume was infused. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.10(c) Resident care policies

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan for one of 12 residents reviewed (Resident 7). Findings Include: Review of the facility's policy, titled Comprehensive Care Plans, recently reviewed May 21, 2025, reads [Facility] will develop a comprehensive care plan for each resident which includes measurable goals and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident 7's physician orders revealed diagnoses that included age-related macular degeneration (an eye disease that affects central vision) and muscle weakness. Review of Resident 7's clinical record revealed outpatient consults with eye professionals for treatment of macular degeneration, including eye injections. Review of Resident 7's interdisciplinary plan of care revealed no care plan regarding the Resident's vision or eye consultations and treatments. An interview with the Nursing Home Administrator on May 29, 2025, at 11:07 AM, confirmed that a care plan related to Resident 7's vision was developed and added to the plan of care. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of a statement of the resident's appeal rights, including the name, address (mailing and email), telephone number of the entity which receives such requests, and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman; and failed to provide notice of the transfer to the Office of the State Long-Term Care Ombudsman for one of two residents reviewed for hospital transfers ( Resident 7). Findings Include: Review of Resident 7's physician orders revealed diagnoses that included age-related macular degeneration (an eye disease that affects central vision) and muscle weakness. Review of Resident 7's clinical record revealed a transfer to the hospital on March 4, 2025. Review of Resident 7's hospital transfer information failed to include documentation of written notice of appeals information provided to the Resident and/or the Representative. Review of the facility's documentation of the monthly notice to the Long-Term Care Ombudsman failed to include Resident 7's hospital transfer. An interview with the Nursing Home Administrator, on May 29, 2025, at 12:06 PM, revealed the facility is not providing appeals information during resident hospital transfers, and also revealed the facility only notifies the Long-Term Care Ombudsman of residents not returning to the facility and does not include residents transferred to the hospital with plans to return. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on a review of the facility's policy, review of the clinical record and hospital records, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of a change in condition for one of the 14 residents reviewed (Resident 92) Findings include: Review of the facility's policy titled Transcription of Physicians Orders with an effectivity date of September 1, 2009, revealed that a resident-centric secure conversation will be started by a nurse only if the situation does not need immediate attention by the practitioner. The practitioner will view the message, may review the resident's chart, then respond to the message with acknowledgment, new order, or questions. Review of the nursing progress notes dated May 3, 2023, revealed Resident 92 was admitted to the facility post small bowel resection (Surgery to remove part of the small intestine). Review of the physician's notes dated May 10, 2023, revealed resident received exploratory laparotomy in the hospital (surgery to open the abdomen to find the cause of the problems that testing could not diagnose), and a small bowel resection. The resident has an abdominal surgical wound with staples which will be followed by the surgeon. The note revealed that during the May 10 (2023) evaluation, the resident was clear and coherent, reported feeling well, and not having any residual abdominal pain. The resident had been eating and drinking well. Vitals were blood pressure- 134/71 mm; heart rate-69 per min.; respirations 16 per min., and temperature 98.1 Fahrenheit (F). Review of the nursing progress notes dated May 16, 2023, at 7:39 p.m., revealed resident appeared tired and flushed in the face. The resident complained of lower back pain, and the temperature was 100.9 F, as needed Tylenol was administered (medication to treat mild pain and fever). Review of the Secure Conversation dated May 16, 2023, at 9:02 p.m., documented by the nursing supervisor, Employee E3, revealed a message with a subject of temperature elevation and complaint of back pain. The message revealed that Employee E3 was notified of a resident not feeling well with a flushed face, the temperature was 100.9 F with mild lower back pain and medication the nurse administered as needed Tylenol order. The resident's temperature was checked at 8:55 p.m. and found to be 97.9F, with no complaint of discomfort or feeling feverish. Conversation participants include Employee E3, Employee E5, and the Nurse Practitioner. Review of the Secure Conversation documentation revealed no response from the practitioner. The clinical records review failed to reveal that a follow-up call/message was sent to the practitioner. Clinical records failed to reveal that the practitioner had received, reviewed, and acknowledged the message sent via secure conversation. Interview conducted with licensed nurse Employee E4 on June 1, 2023; revealed she/he was a regular evening shift nurse of Resident 92. Employee E4 reported approximately 7:00 p.m., the resident's temperature was 101 F. The nurse continued to relay that she/he checked the resident's baseline vitals and confirmed that the temperature was elevated from the baseline. Employee E4 confirmed that she/he never received any previous report of elevated temperature for the resident, and this was the first time he/she had a temperature of 101 F while caring for the resident. Employee E4 confirmed that the elevated temperature was a change in condition for the resident. The nurse notified the nursing supervisor of the resident's condition and administered with needed Tylenol for the fever. Employee E4 reported that the nursing supervisor had reached out to the provider but was not sure of the mode of notification. Employee E4 reported that it was the facility's protocol to notify the nursing supervisor and they are the one who notifies the NP/MD. Employee E4 reported that the incoming shift reported the resident's condition. Review of Resident 92'a May 2023, Medication Administration Record (MAR) revealed Resident 92 was administered with Acetaminophen 500 mg extra strength two tablets (1000mg) on May 16, 2023, at 7:44 p.m. Interview conducted with licensed nurse Employee E5 on June 1, 2023 revealed he/she was the nursing supervisor on May 17, 2023, morning shift. Employee E5 explained that the Secure Conversation are messages sent to the nurse practitioner and used for issues like medications. Employee E5 confirmed that for a resident's significant change in condition, the on-call physician should have been called. Employee E5 reported that upon reading the secure conversation indicating that the resident had an elevated temperature the night before and still with an elevated temperature in the morning, the physician who was in the building was notified. Review of the physician's notes dated May 17, 2023, at 8:50 a.m., revealed resident developed a fever of 101.5 F last night and was given Tylenol, for some reason the on-call physician was not notified of the fever last night. This morning the resident is weak, has a slight cough, and is having difficulty getting out of bed when he/she was prior independent. Spoke with the physical therapist and nurse and they noticed significant change. Resident appears flushed and warm, heart rate was 120 /min., and his temperature is 101F. The Resident complained of slight back pain today, seemed thirsty, appears dyspneic (short of breath), and has a slight cough with some clear mucus. Review of the nursing progress notes dated May 17, 2023, at 11:23 a.m., revealed resident was assessed by the physician and continued with a fever of 100.1 F, the physician ordered to send the resident to the ER (emergency room ) for evaluation and treatment, 911 was called, the wife was notified. Review of the hospital records and discharge summary revealed resident was admitted to the hospital on May 17, 2023, with admitting diagnosis of Sepsis - (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). The problem list revealed sepsis end-organ dysfunction suspected secondary to residual fluid collections, and peritonitis (inflammation of the membrane lining of the abdominal wall and covering abdominal organs) after recent bowel perforation. Possibly UTI (urinary tract infection). Followed by an Infectious Disease doctor and treated with antibiotics. Interview conducted with the Director of Nursing (DON) on June 2, 2023, at 11:00 a.m. confirmed there was no documented evidence the on-call physician was notified of the resident's elevated temperature on the night of May 16, 2023. Clinical records review revealed a Secure Conversation was sent to the NP (Nurse Practitioner) instead calling the on-call physician on the night of June 16, 2023, for Resident 92's complaint of not feeling well, back pain, and elevated temperature. The facility failed to ensure Resident 92's change in condition, elevated temperature was appropriately communicated with the physician. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies

Based on review of facility policy, staff interview, and pharmacy consultant interview, it was determined that the facility failed to implement procedures to ensure accurate accounting of controlled medications (substances that have an accepted medical use [medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V], have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) for one of two medication rooms observed (Team Room [NAME]), and four of 15 resident medication storage boxes observed (Medication storage boxes for Residents 13, 15, 34. and 85). Findings include: A review of the policy from the Pharmacy titled Controlled Substance Storage, with an effective date of July 1, 2015, revealed that at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is to be documented. A review of the controlled medication list from The Controlled Substances Act (www.dea.gov) revealed that Lorazepam, [MEDICATION(S)], and [MEDICATION(S)] fall under Schedule IV medications (drug or other substance with a low potential for abuse). An observation was conducted of the [NAME] Team Room refrigerator on June 9, 2021, at 9:15 a.m. in the presence of Licensed Employee E7. The room did not have a locked door and a small refrigerator (locked) was located inside the [NAME] Team Room. An observation of the medication refrigerator revealed one vial of Lorazepam 2 milligram (mg)/ml (a medication used to treat anxiety) and one bottle of Lorazepam [MEDICATION(S)] oral concentrate 2 mg/ml inside a clear container. An interview with Licensed Employee E7 on June 9, 2021, at 9:15 a.m., revealed that the Lorazepam inside the refrigerator was provided by the pharmacy used as a facility backup medication. Licensed Employee E7 was unable to provide a record of an inventory completed for the backup Lorazepam vial and liquid. Licensed Employee E7 confirmed that the facility does not conduct a personal inventory of Lorazepam medication of the team room's medication refrigerator as well as the Lorazepam kept in the resident's wall medication storage box inside their rooms. An observation of the wall medication storage box of Resident 15 revealed a blister pack of [MEDICATION(S)] (a medication to treat anxiety) kept together with the rest of the resident's non-controlled medication. An interview with Licensed Employee E3 on June 9, 2021, at 1:00 p.m., confirmed that aside from marking in the MAR (Medication Administration Record) that the [MEDICATION(S)] was administered, there was no procedure to ensure an accurate account of the resident's [MEDICATION(S)]. Licensed Employee E3 stated that they rely on the integrity of each other (licensed employees). An observation of the wall medication storage box of Resident 34 on June 10, 2021, at 2:00 p.m. in the presence of Licensed Employee E8, revealed four blister pack of Lorazepam 0.25 mg all containing 15 tablets, one blister pack of Lorazepam 0.25 mg containing 21 tablets, one blister pack of Lorazepam 0.25 mg containing three tablets, and one blister pack of Lorazepam 0.25 mg containing two tablets. An observation of the wall medication storage box of Resident 13 on June 10, 2021, at 2:10 p.m., in the presence of Licensed Employee E8, revealed three blister packs of Lorazepam 0.25 mg, all containing 12 tablets, and one blister of Lorazepam 0.5 mg containing 20 tablets. An interview with Licensed Employee E8 on June 10, 2021, at 2:10 p.m. confirmed that the Lorazepam tablets on the resident's wall medication storage box mentioned above were not counted/accounted for. An observation of the wall medication storage box of Resident 85 on June 10, 2021, at 2:15 p.m., in the presence of Licensed Employee E7, revealed two blister pack of [MEDICATION(S)] (a medication to treat moderate to severe pain) 50 mg, both with two tablets, and one blister pack of [MEDICATION(S)] 50 mg with 1 tablet. An interview with Licensed Employee E7, on June 10, 2021, at 2:15 p.m. confirmed that the [MEDICATION(S)] on the resident's wall storage medication box was not counted/accounted for. A phone interview with the pharmacy consultant on June 9, 2021, at 1:30 p.m. revealed that due to the pandemic, consultation had been done remotely. The pharmacy consultant stated that they were in the facility around two months ago. The pharmacy consultant stated that they were aware that the facility only documents accounting of the Schedule II medications (a drug or substance that has a high potential for abuse) but not the Schedule IV medications. When asked regarding the possibility of medication diversion (The transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use), the pharmacy consultant stated that the pharmacy will be able to identify a concern based on how often the controlled medication was reordered/refilled (ex. reordering too soon). An interview with the Director of Nursing on June 10, 2021, at 1:00 p.m., revealed that there was not a current system in place to ensure accurate accounting of all the controlled medications in the facility. 28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services

Based on a review of the pharmacy policy, and manufacturer's guideline, staff interview, and pharmacy consultant interview, it was determined that the facility failed to ensure that controlled medications (substances that have an accepted medical use [medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V], have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) were stored appropriately and medications were appropriately labeled for two of two medication rooms observed (Team Room Brossmann and [NAME]), and seven of 15 resident medication storage boxes observed (Medication storage boxes of Residents 8, 13, 17, 29, 31, 34. and 85). Findings include: A review of the controlled medication list from The Controlled Substances Act (www.dea.gov) revealed that Lorazepam, [MEDICATION(S)], and [MEDICATION(S)] fall under scheduled IV medication (A drug or other substance with a low potential for abuse). A review of the policy and procedure provided by the Pharmacy Consultant entitled Medication Storage in the Facility, with an effective date of July 1. 2015, revealed Scheduled II medications (a drug or other substance with high potential for abuse), and other medications subject to abuse or diversion are stored permanently affixed, double-locked compartment medications or per state regulation. The access system to controlled medications is not the same as the system giving access to other medications (the key that opens the compartment is different from the key that opens other medication cabinets). Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. A review of the manufacturer's storage guidelines for [MEDICATION(S)]-Purified Protein Derivative (PPD) (a combination of proteins that are used in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [MEDICATION(S)] Eye Solution (a medication to treat eye infection) manufacturer's guidelines revealed to throw away the bottle of eye drops after you have finished the course of the treatment, even if there is some liquid left. An observation of the Brossman's Team Room's medication refrigerator on June 8, 2021, at 10:00 a.m., in the presence of Licensed Employee E10, revealed one bottle of [MEDICATION(S)], opened and undated. During an interview on June 8, 2021, at 10:00 a.m. Licensed Employee E10 stated that she/he does not know when the vial of the [MEDICATION(S)] was opened and also stated that the vial should have been dated when opened. An observation of Resident 17's medication storage box in the room on June 8, 2021, at 9:50 a.m., in the presence of Licensed Employee E3, revealed one bottle of [MEDICATION(S)] eye drops, used, and undated. An observation of Resident 31's medication storage box in the room on June 8, 2021, at 10:30 a.m., in the presence of Licensed Employee E8, revealed one bottle of [MEDICATION(S)] eye drops labeled as opened on February 1, 2021. An observation of Resident 29's medication storage box in the room on June 8, 2021, at 10: 35 a.m., in the presence of Licensed Employee E8 revealed one bottle of [MEDICATION(S)] eye drops, used, and undated. Two white pills in a medication cup were also observed. An interview with Employee E8 on June 8, 2021, at 10:40 a.m. confirmed that the eye drops should have been dated when opened and discarded after the completion of the treatment. Licensed Employee E8 stated that as per the medication nurse, the two white pills in the medication cup were Tylenol. Licensed Employee E8 agreed that the medication should have been in its original container. An observation of the [NAME] Team Room refrigerator on June 9, 2021, at 9:15 a.m. in the presence of Licensed Employee E7 was conducted. The room does not have a locked door and a small refrigerator (locked) was located inside the [NAME] team room. An observation of the medication refrigerator revealed a large plastic container with a cover, containing one vial of Lorazepam 2 milligrams (mg)/ml (a medication used to treat anxiety), one bottle of Lorazepam [MEDICATION(S)] oral concentrate 2 mg/ml, and two insulin pens. The plastic container was not affixed to the refrigerator and does not have a lock system. An observation of Resident 15's medication storage box in the room on June 9, 2021, at 1:00 p.m. revealed a blister pack of [MEDICATION(S)] (a medication to treat anxiety) stored with the rest of the resident's non-controlled medications. An observation of Resident 34's medication storage box in the room on June 10, 2021, at 2:00 p.m. in the presence of Licensed Employee E8, revealed four blister packs of Lorazepam stored with the rest of the resident's non-controlled medications. An observation of Resident 13's medication storage box in the room on June 10, 2021, at 2:10 p.m. in the presence of Licensed Employee E8, revealed three blister packs of Lorazepam stored with the rest of the resident's non-controlled medications. An observation of Resident 85's medication storage box in the room on June 10, 2021, at 2:15 p.m. in the presence of Licensed Employee E7, revealed two blister pack of [MEDICATION(S)] (a medication to treat moderate to severe pain) stored with the rest of the resident's non-controlled medications. The above was conveyed to the Director of Nursing on June 10, 2021, at 1:00 p.m. The facility failed to properly store controlled medication and label medications. 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide an indication for the administration of psychoactive (affecting the mind) medication and failed to ensure that non-pharmacological interventions were attempted prior to the use of psychoactive medication for one of 12 residents reviewed (Resident 15). Findings include: A review of the facility's policy and procedure entitled Psychoactive Medication Monitoring, with a revision date of August 9, 2017, revealed that when a resident is experiencing a distressing behavior, the nurse will first attempt non-pharmacological interventions. The behaviors, the non-pharmacological interventions, and outcomes must be documented on the Behavior/Intervention Monthly Flow Record. If the non-pharmacological interventions were unsuccessful in correcting the behaviors, the nurse may administer a prescribed medication indicated for that behavior. That the nurse must also document in the resident's clinical record a summary of the behaviors, non-pharmacological interventions attempted and the effectiveness, the name and dose of the medication administered, the effect of the medication on the resident's behavior, and if any side effects were experienced. A review of Resident 15's diagnosis list revealed urinary tract infection, Alzheimer's disease (Irreversible, progressive [CONDITION(S)] disease of the brain, resulting in loss of reality contact and functioning ability), and dementia with behavioral disturbances), and dementia with behavioral disturbances. A review of Resident 15's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated April 20, 2021, revealed that the resident had a BIMS (Brief Interview for Mental Status) of 14 which placed the resident as being cognitively intact. A review of Resident 15's physician's orders dated April 30, 2021, revealed an order for ABH gel ([MEDICATION(S)] 1 milligram (mg)/[MEDICATION(S)] 25 mg/[MEDICATION(S)] 2 mg- [a compounded medication for the treatment of nausea, vomiting, and terminal [CONDITION(S)], usually prescribed for individuals in Hospice and palliative setting]), apply to the skin topically in the evening related to Dementia with behavioral disturbances and apply to the skin topically PRN (as needed) for restlessness, agitation, and anxiety twice daily. On May 4, 2021, the dosage of the medication was changed to [MEDICATION(S)] 1 mg/[MEDICATION(S)] 25 mg/ [MEDICATION(S)] 1 mg as recommended by the pharmacy in which the physician agreed and was ordered. A review of Resident 15's May 2021 Medication Administration Record (MAR) revealed that aside from the routine ABH gel the resident was receiving every evening shift; the resident was administered with PRN ABH gel 13 times. A review of Resident 15's progress notes and Behavior Monitoring Form revealed that the resident was administered with as needed PRN ABH gel seven times on May 2021, without a documented behavior and/or reason as to why the PRN medication was administered (May 1, 2021, at 9:41 a.m., and 2:16 p.m., May 4, 2021, at 12:30 p.m., May 7, 2021, 6:06 p.m., May 14, 2021, at 12:14 p.m., May 17, 2021, at 4:39 a.m., and May 22, 2021, at 11:16 p.m.). There was also no documented evidence that a non-pharmacological intervention was attempted prior to the administration of the PRN ABH gel prior to the above-mentioned dates. The above was discussed with the Director of Nursing on June 10, 2021, at 11:00 a.m. The facility failed to provide a behavior/and or reason for the administration of PRN ABH gel to Resident 15 and failed to attempt to provide a non-pharmacological intervention prior to the administration of the ABH gel. 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to conduct a comprehensive and timely investigation for an alleged emotional and verbal abuse for one of the 12 residents reviewed (Resident 4). Findings include: A review of the facility's policy titled Abuse Prihibition-Abuse Investigation, with a revision date of August 12, 2016, revealed that the facility will thoroughly investigate and document all allegations of Abuse, Neglect, Mistreatment, and Misappropriation of Property. All alleged incidents of abuse will be immediately reported to the Administrator or Director of Nursing. The investigation will be initiated upon notification. The Administrator/DON will oversee the investigation. The investigation will include interviews and statements from all interviewable residents, staff, and other witnesses. It will also include a thorough prompt examination of the resident if injury is suspected. A review of Resident 4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated March 16, 2021, revealed that the resident had severe cognitive impairment. A review of Resident 4's progress notes dated April 6, 2021, at 12:50 p.m., revealed that the Nursing Assistant (NA's) heard the resident's husband tell the resident that he would not visit anymore if she does not eat her lunch. The husband's behavior was reported to the Social Worker (SW). A review of Resident 4's progress note dated April 7, 2021, at 8:20 p.m., revealed that the NA heard Resident 4's husband becoming verbally aggressive toward the resident during dinner time. The husband was asked to step out of the room and he became very upset. The husband was escorted to the front door, after he left the building, the resident became tearful. A review of the SW's progress note dated April 8, 2021, at 11:41 a.m., revealed that the SW met with Resident 4's husband. The note revealed that there have been more reports of staff overhearing the resident's husband being verbally aggressive with the resident. It was determined that the incident often happens around mealtime. The resident's husband won't be allowed to visit at mealtimes. The note also revealed that the husband stated that he feels depressed and was having an emotional problem related to the resident's decline. A review of Resident 4's clinical record failed to reveal that an investigation was conducted upon reporting the incident of alleged emotional and verbal abuse of the the husband toward the resident to the SW on April 6, 2021. Interview with the Social Worker in the presence of the Director of Nursing on June 10, 2021, at 10:49 a.m., confirmed that she/he was informed by the staff regarding the incident on April 6, 2021. The SW was unable to recall if she/he had spoken to the resident's husband on the day that it was reported to her/him. The SW and the DON confirmed that there were no statements taken from the staff who reportedly overheard and witnessed the husband being verbally aggressive to the resident. There were no documented statements obtained from other residents who might have potentially witnessed the incident. The facility failed to thoroughly and timely investigate an alleged emotional and verbal abuse of the husband toward Resident 4. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical record, observations, and resident and staff interview, it was determined that the facility failed to comprehensively assess and implement interventions regarding suicide ideation for one of 12 residents reviewed (Resident 15). Findings include: A review of the facility policy entitled Suicide Precaution Policy, with a revision date of August 1, 2016, revealed that Active Suicide Ideation is defined as extensive and detailed thoughts of taking action toward hurting oneself. The policy process includes: The nursing supervisor and social worker will be notified when any resident voices suicidal ideation; The social worker or nursing manager will follow the facility protocol for evaluating the level of suicidal risk using a P4 screening tool, and document this in the resident's clinical record; All items that were mentioned by the resident as the instrument of harm, or have the potential cause harm to the resident will be removed from the room by nursing or social services staff immediately (call bell cord, extra trash bag, metal silverware, razor blades, etc.); The kitchen will be notified to provide the resident with plastic silverware if deemed necessary; Based on the suicidal risk assessment and level of risk determined, a plan of care will be developed with interdisciplinary coordination; and The resident will continue with interventions put in place to ensure safety until evaluated by the psychologist and/or social worker. A review of the Resident 15's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 15's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated April 20, 2021, revealed that the resident was cognitively intact and required supervision with locomotion on and off the unit. The same MDS also revealed that the resident had verbalized feeling down, depressed, or hopeless several days for the last two weeks. The MDS also revealed that the resident had exhibited episodes of verbal and physical aggression. A review of Resident 15's progress note dated May 1, 2021, at 3:20 p.m., revealed that the resident had stated that she/he is going to hurt herself/himself. Also stated that she/he wished to have a knife. Suicide precautions started. The Dietary department was informed to give the resident a plastic utensil. An observation on June 9, 2021, at 9:45 a.m. revealed the resident was eating breakfast, regular silverware (fork and bread knife) were observed on the tray table. An interview with Resident 15 was conducted on June 9, 2021, at 9:50 a.m. The resident started crying when approached, stated she/he was upset for not getting a visit from his/her brother. The resident refused to answer questions and continued to cry. An observation of Resident 15 on June 9, 2021, at 12:40 p.m. revealed that the resident was eating lunch in the room, with a metal fork and bread knife on the meal tray. An interview with Licensed Employee E3 on June 9, 2021, at 1:00 p.m. revealed that she/he does not have any information that the resident required a special/plastic utensil during meals. Licensed Employee E3 stated that the resident had always been using a metal utensil. An interview with Employee E5 and Employee E6 on June 9, 2021, at 1:15 p.m., revealed that both had previously taken care of Resident 15. Both employees stated that the resident had always used a metal utensil during the meal and did not have any information that the resident was supposed to use a plastic utensil. An interview with the Director of Nursing on June 10, 2021, at 10:40 a.m., revealed that the facility cannot provide any evidence that the kitchen was notified that Resident 15 would only use a plastic utensil as a precaution for the resident's suicidal ideation. An interview with Social Worker (SW), Employee E4 on June 10, 2021, at 10:49 a.m. revealed that the staff informed her/him of Resident 15's suicidal ideation on May 1, 2021. SW Employee E4 confirmed that the facility's protocol to complete the suicidal risk screening tool (P4) was not done for Resident 15. A review of Resident 15's clinical record revealed that the resident was being followed by a behavioral health provider, the resident was last seen on April 19, 2021. The resident was seen again by the behavioral health provider on May 21, 2021, for a routine visit, 20 days after the resident had verbalized suicidal ideation. A recommendation was made and ordered for the resident to start on [MEDICATION(S)] (A forms are medications primarily used to treat [CONDITION(S)] and [CONDITION(S)] disorder and prevent migraine headaches) 125 milligrams two times daily for a mood stabilizer, and behavioral disturbance. An interview with Employee E4 on June 10, 2021, at 3:00 p.m., stated that the resident was not referred to the behavioral health provider after the resident had verbalized suicidal ideation. The visit made by the behavioral health provider on May 21, 2021, was part of their routine visit. The facility failed to conduct a comprehensive assessment and implement interventions regarding Resident 15's suicidal ideation. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident was comprehensively assessed for participation in a bladder retraining program for one of eight residents reviewed (Resident #31). Findings include: Review of Resident #31's [DIAGNOSES REDACTED]. A review of Resident #31's MDS (Minimum Data Set - an assessment tool used to facilitate the management of care) dated (MONTH) 28, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 15, which identified the resident as cognitively intact. Under Section G Functional Status, Toilet, the resident was assessed with [REDACTED]. Under Section H Bladder and Bowel, Resident #31 was occasionally incontinent of bladder. Review of facility documentation revealed that Resident #31 had four episodes of urine incontinence from (MONTH) 21, 2019, until (MONTH) 28, 2019. Resident #31's Bowel and Bladder assessment dated (MONTH) 1, 2019, revealed that Resident #31 was assessed by the facility as continent of urine. Further review of the same bowel and bladder assessment revealed that Resident #31 was precluded from participating in a training program because Resident #31 was continent of both bowel and bladder. Review of facility documentation revealed that Resident #31 had a total of 12 episodes of urinary incontinence from (MONTH) 23, 2019, to (MONTH) 1, 2019. Resident #31's quarterly MDS assessment dated (MONTH) 23, 2019, revealed that Resident #31 was frequently incontinent of bladder, a decline from the previous urine continence assessment, which was occasionally incontinent. Review of facility documentation revealed that Resident #31 had a total of 10 episodes of urine incontinence from (MONTH) 16, 2019, to (MONTH) 23, 2019. There was no documented evidence that Resident #31 was comprehensively assessed with [REDACTED]. The facility failed to assess Resident #31's urinary continence accurately and comprehensively for the participation of a bladder retraining program. 28 Pa. Code 211.5(f) Clinical records Previously cited 8/24/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/24/18

Based on a review of facility policy, residents group interview, resident and staff individual interviews, it was determined that the facility failed to make certain residents were notified of the procedure for filing grievances anonymously on two of two nursing units (Brossman and Franzen nursing units). Findings include: Review of the facility policy dated (MONTH) 28, (YEAR), titled, Grievance Policy-Resident Rights provided to residents on admission indicated that residents have the right to information on how to file a grievance or concern. The policy further stated that Grievances may be communicated anonymously utilizing designated Grievance forms. Durign a residents group interview conducted on (MONTH) 23, (YEAR) at approximately 11:20 a.m. with six alert and orientated residents living on the Brossman and Franzen Nursing Units, revealed that these residents were asked if they knew how to file a grievance or a concern and how they would file anonymously. All six residents were unclear on how to file anonymously and they were unaware of the location of Grievance/Concern forms. During an observation on the Brossman Nursing Unit on (MONTH) 23, (YEAR) at approximately 12:00 p.m. noted that the process of filing a grievance anonymously was not displayed and no Grievance/Concern Forms were visible on the unit. During an observation on the Franzen Nursing Unit on (MONTH) 23, (YEAR) at approximately 12:15 p.m. the policy for filing grievances/concerns was in a binder on a bench as you entered the unit, but no Grievance/Concern Forms were visible on the unit. During an interview on (MONTH) 24, (YEAR) at approximately 9:15 a.m. on the Franzen Nursing Unit, the Administrator confirmed that although the grievance policy was displayed on the Franzen unit in a binder explaining the grievance process, there was no way for a resident or family to file an anonymous grievance and grievance/concern forms are not accessible to resident or families without asking a staff member. Pa. 28 Code: 201.29(i) Resident Rights. Pa. 28 Code: 201.18(e)(4) Management.

Based on review of facilty policy and clinical record review a, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of one resident reviewed (Resident# 16). Findings include: Review of facility's policy, titled Pain Management dated (MONTH) 17, (YEAR) revealed that if a resident has additional as needed pain medication options above and beyond the standing Tylenol, parameters will be included within the order to help clarify which medication should be administered. Review of Resident #16's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident #16's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #16's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of Resident #16's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #16's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident #16's MAR for (MONTH) (YEAR) revealed administration of Tylenol 650 mg on (MONTH) 1, (YEAR) for pain level of 5, (MONTH) 2, (YEAR) for a pain level of 5, (MONTH) 16, (YEAR) for pain level of 5 and (MONTH) 18, (YEAR) for pain level of 5. Interview with the Director of Nursing on (MONTH) 24, (YEAR), at 2:20 p.m confirmed that there are no parameters in place in determining which pain medication should be administered. 28 Pa. Code 211.5(f) Clinical Record Previously cited 9/22/2017 28 Pa Code 211.10 Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 9/22/2017

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure for one of one residents reviewed following a fall incident received effective pain management.(Resident #23). Findings include: Review of facility's policy, titled Pain Management dated (MONTH) 17, (YEAR) revealed its purpose to prevent and/or manage pain in order to help the residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. In addition, if pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated. Review of Resident #23's clinical record revealed the resident [DIAGNOSES REDACTED]. Review of Resident #23's Quarterly MDS (Minimum Data Set- resident assessment and care screening), dated (MONTH) 19, (YEAR) Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 99 which reflects severe cognitive impairment, unable to complete interview. Review of Resident #23's nursing notes dated (MONTH) 1, (YEAR) revealed Resident #23 was found on floor in his room at 6:15 p.m. Documentation provided by the facility to the State Agency revealed, it appears resident attempted to get out of wheelchair and tripped over wheelchair pedals. Licensed nursing staff, Employee E4 documented on (MONTH) 1, (YEAR) at 8:00 p.m. that resident was noted to have discomfort with grimacing with movement to left hip/thigh/knee movement. Further review of Resident #23's clinical record noted to have no further documentation of fall of (MONTH) 1, (YEAR) in progress notes until (MONTH) 6, (YEAR) at 6:48 a.m. when Resident #23 was noted to have increased left leg pain. Bruise to posterior left thigh. Tylenol given with minimal effectiveness. Further review of Resident #23's nursing notes from Licensed nursing staff, Employee E6 dated (MONTH) 6, (YEAR) at 7:10 a.m. revealed resident complained of pain to left hip, unable to bear weight and yelled out in pain. Upon assessment by Licensed nursing staff, Employee E6, the resident's left leg had increased [MEDICAL CONDITION] from knee to hip, leg leg shorter than right leg, and externally rotated with bruising to posterior left thigh. The Certified Registered Nurse Practitioner (CRNP) notified and an x-ray was ordered. The x-ray revealed that the resident sustained [REDACTED]. Review of Resident #23 nursing note dated (MONTH) 6, (YEAR) indicated that the resident was transferred to the hospital at 10:15 a.m. Review of facility's investigation in relation to Resident #23's left femoral fracture including witness statements revealed an statement obtained from licensed nursing staff, Employee 5 noted due to Resident #23 complaints of severe leg pain there was a decrease in ambulation and weight bearing during therapy. A heat treatment was provided, pain was better, but still extensive. On (MONTH) 3, (YEAR) during physical therapy session, physical therapy staff, Employee E8 noted that Resident #23 demonstrated signs of discomfort/pain in left hip area. Employee E8 discontinued walking session due to resident's reports of pain and discomfort. Review of non licensed nursing staff, Employee E9 revealed that on (MONTH) 4, (YEAR) during the night shift, Resident #23 was having a lot of pain when putting weight on left leg. Also, resident required assistance of one with transfers. Non licensed nursing staff, Employee, E9 revealed that on Saturday (August 4, (YEAR)) Resident #23 was observed with a bruise on left upper leg. On Sunday (August 5, (YEAR)) Resident #23 was not able to transfer at all and was in too much pain to get up. In the morning, two nursing assistants were required to get Resident#23 out of bed for morning care and bruise on left leg was much worse than Saturday. Additional review of the investigation revealed a statement from licensed Employee, E5 on (MONTH) 4, (YEAR) which indicated that the resident was noted to have pain with movement, Resident #23 stated it hurts, it's not good. On (MONTH) 5, (YEAR) licensed nursing staff Employee E5 revealed that staff reported that Resident #23 had increased difficulty with transfers and complaints of pain with movement. Review of Resident #23's physician's orders [REDACTED]. Review of Resident #23's Medication Administration Record [REDACTED] There was no documented evidence that the resident's physician was notified of the resident continues complaints of pain on (MONTH) 2-3, (YEAR) during physical therapy session, (MONTH) 4, (YEAR) during the night shift, and (MONTH) 5, (YEAR) with decrease ambulation to appropriately manage Resident #23 pain level. This was confirmed with the Director of Nursing and Administrator on (MONTH) 24, (YEAR) at approximately 2:30 p.m. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to assess resident's nutritional status and failed to identify and implement interventions to address weight loss for one of seven residents reviewed (Resident 41). Findings include: Review of Resident 41's clincial record revealed Resident 41 was admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 41's Weights and Vitals Summary from (MONTH) 21, (YEAR) through and including (MONTH) 21, (YEAR) revealed Resident 41's weights as follows: (MONTH) 3, (YEAR) - 172.7 pounds; (MONTH) 4, (YEAR) - 169.1 pounds; (MONTH) 6, (YEAR) - 170.5 pounds; (MONTH) 14, (YEAR) - 159 pounds; (MONTH) 20, (YEAR) 150.8 pounds; and (MONTH) 21, (YEAR) - 153.1 pounds. Review of Resident 41's comprehensive care plan dated (MONTH) 22, (YEAR) revealed Resident 41 had an actual or potential risk for altered nutritional status related to recent fracture of right femur upon admission to the facility. The resident need for therapeutic diet with a history of [MEDICAL CONDITIONS]. Further review of the resident's comprehensive care plan revealed Resident 41 will maintain weight within 5 percent of admission weight through review without any significant changes. Review of Resident 41's nursing progress notes dated (MONTH) 14, (YEAR) revealed re-weight - 11.5 pounds. MD (physican) and dietary notified. Review of Resident 41's nursing progress notes dated (MONTH) 16, (YEAR) revealed wt. loss 2.2 lbs. since 8/13/18 dietary and MD notified. Review of Resident 41's nursing progress notes dated (MONTH) 21, (YEAR) revealed resident with 5.9 weight loss. MD and dietary were notified. Appetite poor. Needing fed at times. Review of Resident 41's nursing progress notes dated (MONTH) 24, (YEAR) revealed weekly meal percentage range 26-50%. Weight loss of just over 18 pounds since 8/1. Receives no supplements at this time. Dietary and MD notified. Review of Resident 41's Nutrition Follow-up assessment dated (MONTH) 6, (YEAR) revealed Resident is stable since his admission. PO (by mouth) intakes are good daily (avg currently 85%) on his Heart Healthy, LCS (low concentrated sweets) diet. Further review of this assessment revealed will cont to follow prn (as needed) and as per MDS schedule. At this time no new interventions or recommendations to make. Will continue to follow. Review of Resident 41's clinical record failed to reveal any further Nutrition Follow-up Assessments for Resident 41 following a 19.6 pounds weight loss from (MONTH) 3, (YEAR) to (MONTH) 21, (YEAR). Review of Resident 41's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Director of Nursing on (MONTH) 24, (YEAR) at approximately 2:30 p.m. confirmed that Resident 41's weight loss was not addressed by the facility's dietician. 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/22/17 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview, it was determined the facility failed to ensure assessments accurately reflect residents' status for one of 21 residents reviewed (Resident 10). Findings include: Review of Resident 10's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 10's Annual Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 1, (YEAR) revealed Resident 10's ability to express ideas and wants was usually understood and Resident 10 was able to understand verbal content. Further review of Resident 10's Annual MDS revealed that the Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely/never understood, therefore a BIMS interview was never conducted to determine the level of Resident 10's cognitive ability. Review of Resident 10's Quarterly MDS dated (MONTH) 7, (YEAR) revealed that Resident 10 last received the Influenza Vaccine on (MONTH) 13, (YEAR). Review of Resident 10's clinical record revealed that Resident 10's Influenza Vaccine was last received on (MONTH) 5, (YEAR). Interview with Employee E3 on (MONTH) 24, (YEAR) at approximately 10:00 a.m. confirmed that the above mentioned Minimum Data Sets were incorrectly completed and submitted. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the physician of a change in condition following a fall incident for one of seven residents reviewed (Resident #23). Findings include: Review of Resident #23's clinical record revealed the resident [DIAGNOSES REDACTED]. Review of Resident #23's quarterly MDS (Minimum Data Set- resident assessment and care screening), dated (MONTH) 19, (YEAR) Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) of 99 which reflects severe cognitive impairment, unable to complete interview. Section G, Functional Status revealed transfer status of independent with set up help only, walking in room independent status, and toileting status limited assistance of one person. Review of Resident #23's nursing notes dated (MONTH) 1, (YEAR) revealed Resident #23 was found on floor in his room at 6:15 p.m. it appears resident attempted to get out of wheelchair and tripped over wheelchair pedals. This was an unwitnessed fall, Licensed nursing staff Employee, E4 documentated on (MONTH) 1, (YEAR) at 8:00 p.m. that resident was noted to have discomfort with grimacing with movement to left hip/thigh/knee movement. Further review of Resident #23's nursing notes dated (MONTH) 6, (YEAR) at 6:48 a.m. revealed Resident #23 was noted to have increased left leg pain. Licensed nursing staff Employee, E5 documented that the resident had an x-ray on (MONTH) 30, (YEAR) as a result of a previous fall on (MONTH) 28, (YEAR) which was negative for an acute fracture. Bruise to posterior left thigh. Tylenol given with minimal effectiveness. Further review of Resident #23's nursing notes from Licensed nursing staff, Employee E6 dated (MONTH) 6, (YEAR) at 7:10 a.m. revealed resident complained of pain to left hip, unable to bear weight and yelled out in pain. Upon assessment by Licensed nursing staff, Employee E6, the resident's left leg had increased [MEDICAL CONDITION] from knee to hip, leg leg shorter than right leg, and externally rotated with bruising to posterior left thigh. The Certified Registered Nurse Practitioner (CRNP) notified and an x-ray was ordered. The x-ray revealed that the resident sustained [REDACTED]. The resident was transferred to the hospital at 10:15 a.m. as ordered by the CRNP. Review of facility's investigation in relation to Resident #23's left femoral fracture including witness statements revealed an statement obtained from licensed nursing staff, Employee 5 noted due to Resident #23 complaints of severe leg pain there was a decrease in ambulation and weight bearing during therapy. A heat treatment was provided, pain was better, but still extensive. On (MONTH) 3, (YEAR) during physical therapy session, physical therapy staff, Employee E8 noted that Resident #23 demonstrated signs of discomfort/pain in left hip area. Employee E8 discontinued walking session due to resident's reports of pain and discomfort. Review of non licensed nursing staff, Employee E9 revealed that on (MONTH) 4, (YEAR) during the night shift, Resident #23 was having a lot of pain when putting weight on left leg. Also, resident required assistance of one with transfers. Non licensed nursing staff, Employee, E9 revealed that on Saturday (August 4, (YEAR)) Resident #23 was observed with a bruise on left upper leg. On Sunday (August 5, (YEAR)) Resident #23 was not able to transfer at all and was in too much pain to get up. In the morning, two nursing assistants were required to get Resident#23 out of bed for morning care and bruise on left leg was much worse than Saturday. Additional review of the investigation revealed a statement from licensed Employee, E5 on (MONTH) 4, (YEAR) which indicated that the resident was noted to have pain with movement, Resident #23 stated it hurts, it's not good. On (MONTH) 5, (YEAR) licensed nursing staff Employee E5 revealed that staff reported that Resident #23 had increased difficulty with transfers and complaints of pain with movement. Bruise was noted on posterior left thigh. Statement from licensed nursing staff, Employee, E6 revealed that Resident #23's pain did seem more frequent after fall. Review of Resident #23's entire clinical record revealed no documented evidence that the physician was notified of the identification of a bruise on Resident #23 left upper leg, difficulty with transfers and complaints of pain with movement. These findings were reported to the Administrator and Director of Nursing on (MONTH) 24, (YEAR) at approximately 2:20 p.m. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that physician's orders [REDACTED]. Findings include: Review of facility policy, Pain Management, revised July 3, 2016, indicated that if a medication is given to treat a resident's pain, the Medication Administration Record [REDACTED]. Review of Resident C1's physician's orders [REDACTED]. There were no parameters in place to direct how staff would administer the most appropriate medication for the pain experienced by the resident. Review of Resident C1's July 2017 Medication Administration Record [REDACTED]. Review of the August 2017 MAR indicated [REDACTED]. Review of the September 2017 MAR indicated [REDACTED]. Review of Resident D9's physician's orders [REDACTED]. There were no parameters in place to direct how staff would administer the most appropriate medication for the pain experienced by the resident. Review of D9's July 2017 MAR indicated [REDACTED]. Review of the August 2017 MAR indicated [REDACTED]. Interview with the Director of Nursing on September 21, 2017, at 2:20 p.m confirmed that there are no parameters in place in determining which pain medication should be administered for Resident C1 and D9. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(5) Nursing services

Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure that an allegation of neglect was reported to the State survey and certification agency for one of three residents reviewed. (Resident A9) Findings include: Review of facility documentation regarding an allegation of possible abuse revealed that on September 6, 2016 during the interview conducted by the facility, Resident A9 stated that a nursing assistant forgot him on the bed pan. An interview on September 20, 2016 with the Nursing Home Administrator at approximately 10:15 a.m. revealed that this allegation of neglect was not reported to the State survey agency as required. 28 Pa. Code: 201.18(b)(1)(2)(e)(1) Management 28 Pa. Code 211.12 Nursing (c)(d)(3)(5) 28 Pa. Code 201.29 Residents rights (c)

Based on review of clinical records, facility's policy and staff interview, it was determined that the facility failed to provide adequate assistance during bed mobility, ensure the safety for one of 11 residents which resulted in actual harm to Resident C38. Findings include: Review of the facility's policy for bed making stated in step four: Raise the side rail on the side you would like the resident to turn toward. 5. Assist the resident to turn on his/her side away from you. 6. Fold or roll soiled linen toward the resident and tuck against the resident ' s back. Review of Resident C38 ' s clinical record review revealed the resident was admitted in February 2009 with the following Diagnoses: [REDACTED]. Review of the resident ' s Quarterly MDS (Minimum Data Sheet) dated November 13, 2014 identified the resident as requiring extensive assistance for bed mobility of two person physical assistance. Review of Resident C38's nursing notes dated December 4, 2014 revealed that the resident was incontinent in bed and needed the bed linens changed. According to the facility's investigation Resident C38 was rolled onto her right side (away from the staff member) while the nursing assistant rolled the bed linens to the middle of the bed at this time the resident shifted and fell out of bed hitting her head and her shoulder landing on the floor. Resident C38 was sent out to the hospital for an evaluation. Further review of nursing documentation revealed that the resident returned to the facility on [DATE]. Nursing note dated December 5, 2015 noted that an x-ray report completed at the hospital revealed fracture to the right clavicle. Further review of the clinical chart and Resident C38 ' s care plan revealed that the facility did not provide information on how to provide care for the resident in regards to her left sided hemiparesis in relation to ADL ' s and assistance needed. The care plan did not address how the resident was to reposition in bed if the bed rails were not used. Interview with the Director of Nursing occurred on August 10, 2015 at approximately 2:00 p.m. stating that the resident did not want half side rails all the time, but did not know why side rails were not used for care. Director of Nursing did acknowledge that the care plan did not appear to address the issue of the left sided hemiparesis for ADL ' s especially during bed mobility. The facility failed to provide Resident C38 proper assistance of two people for bed mobility as it was indicated in the resident's assessment completed on November 13, 2015 which resulted in the resident sustaining a fall with a fracture to the right clavicle. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/11/2015 28 Pa Code 211.11(a)(d) Resident Care Plan 28 Pa. code 211.12(d)(5) Nursing services. Previously cited 9/11/2015