Every finding on record at Maple Ridge Rehabilitation & Healthcare Center

Based on review of facility policies, clinical records, documentation provided by the facility, and interviews with the resident, law enforcement, and staff, it was determined that the facility failed to permit a resident to remain in the facility for one out of five residents reviewed (Resident CR1). Findings include: A review of the facility policy titled Out on Pass Unaccompanied Policy, last reviewed by the facility on May 19, 2026, revealed it is the facility policy to maintain the resident's highest practicable level of independence, resident rights, and safety regarding leaving the facility unaccompanied. The policy indicates that unless specified by a physician, a competent resident may exercise his or her right to leave the facility unaccompanied by staff after completing the following procedure. 1. Review the resident responsibility to sign in and out every time he leaves the facility. 2. Sign the resident education leaving unaccompanied form, which shall be placed in the resident's medical record and which delineates the potential risk the resident may incur. 3. Notify facility staff prior to leaving the facility. Should the resident's right to leave the facility unattended be restricted for any reason, the nurse will obtain a physician's ordering indicating such. A review of the facility policy titled Discharging a Resident without a Physician's Approval, last reviewed by the facility on May 19, 2026, revealed it is the facility's policy that if a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs or appears unsafe, the facility will treat this situation similarly to refusal of care and will: (a) Discuss with the resident and document the implication and/or risks of being discharged to a location that is not equipped to meet his needs and attempt to ascertain why the resident is choosing that location. (b) Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; (c) document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; and (d) determine if a referral to adult protective services or another state entity charged with investigating abuse and neglect is necessary. A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that included idiopathic epilepsy (a brain disorder causing repeated seizures where the exact cause is unknown) and a history of a brain tumor with residual effects, with no evidence of an active brain cancer diagnosis. A review of the facility's admission Contract signed by Resident CR1 on September 4, 2024, revealed each resident has the right to remain in the facility and not be summarily transferred or discharged from the facility. The contract indicates each resident shall have the right to be notified of the transfer or discharge and the reasons therefor, at least 30 days before his or her transfer or discharge. The contract indicates each resident shall have the right to appeal his or her transfer or discharge through the appropriate agency as designated by law. A review of Resident CR1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2026, 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 is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident CR1's quarterly MDS Assessment Section Q- Participation in Assessment and Goal Setting dated June 10, 2026, revealed there is no active discharge planning occurring for the resident to return to the community. Resident CR1 indicated that he does not want to talk to someone about the possibility of leaving the facility and returning to live in the community and receiving services in the community. A review of physician's orders as of August 6, 2026, revealed no documented restrictions for Resident CR1 to leave the facility unaccompanied. A progress note dated August 6, 2026, revealed Resident CR1 was discharged from the facility against medical advice (AMA). A discharge against medical advice form dated August 6, 2026, revealed the associated risks and potential complications of the resident leaving the facility. The document indicated the resident releases the nursing facility and its employees from any liability for any adverse results caused by the resident leaving the facility prematurely. The form indicated that medications administered that day and scheduled medications were reviewed. The form indicated Resident CR1 refused to sign the document. A witness statement provided by Employee 1, Licensed Practical Nurse (LPN), indicated that on August 6, 2026, at 10:45 AM, Resident CR1 came to the nurses' station and stated, Can you sign me out? I'm going for my glasses, and then he proceeded to the elevator. A witness statement provided by Employee 2, Receptionist, indicated that on August 6, 2026, Resident CR1 entered the lobby from the elevator. He stated that he was going for his eye appointment. Employee 2 told the resident to stay in the lobby and wait for the van driver. Resident CR1 proceeded to walk out of the building and into the parking lot. Employee 2 notified the DON. A witness statement provided by Employee 3, Assistant Director of Nursing (ADON), revealed that on August 5, 2026, at 10:55 AM, she noticed Resident CR1 walking out the door and heard Employee 2, Receptionist, ask him to sign out for a leave of absence (out on pass), but the resident refused to sign the form. Employee 3, ADON, followed Resident CR1 out of the building, and he indicated that he was going to the eye doctor. She reported that Resident CR1 said he had informed the staff about his destination and refused to sign any documents. Employee 3, ADON, informed Resident CR1 that without signing the leave of absence form, he is considered leaving the facility against medical advice and would be discharged from the facility. Resident CR1 cursed at Employee 3, pushed Employee 3, and then continued to his eye appointment. Employee 3, ADON's statement indicated the Nursing Home Administrator (NHA) arrived and provided the discharge against medical advice form and indicated the resident refused to sign. Employee 3, ADON, indicated that Resident CR1 said his plan was to go back to the facility, pack his things, then leave. The resident indicated he was figuring out his plans for where to go. Upon returning to the facility, Resident CR1 began to pack his belongings, then proceeded to sit in the dining room and refused to leave. A witness statement provided by the Nursing Home Administrator (NHA) indicated that on August 6, 2026, at 12:30 PM, Resident CR1 returned to the facility and refused to look at any paperwork and returned to his room. Resident CR1 packed his belongings and made phone calls in the dining room. Resident CR1 refused to speak with staff. The facility's leave of absence policy, the risks of leaving the facility against medical advice policy, and the medication list were discussed with the resident. The resident reported to the facility that he was leaving soon and was waiting for a ride. The NHA indicated that at 3:30 PM multiple staff attempted to discuss with Resident CR1 when he would be leaving the property and informed him that he could no longer stay at the facility as a discharged resident. The NHA indicated the resident became verbally aggressive, stating, I know my rights to a private phone call. You need to f**king leave. The NHA indicated that at 5:15 PM, after the resident continued refusing discharge documentation, refused available resources, and confirmed his intent to leave the facility permanently, the facility completed an AMA discharge in the electronic health record. The NHA explained that at 6:00 PM, local police responded to the facility regarding harassment charges filed against Resident CR1 and escorted him from the premises. During a phone interview on August 26, 2026, at 10:32 AM, the responding police officer indicated that on August 6, 2026, he was notified by the facility that a discharged resident refused to leave the premises. The officer escorted Resident CR1 from the facility. The officer explained that Resident CR1 indicated that he did not want to leave, but the resident complied, stating he didn't want any trouble with law enforcement. During a phone interview on August 26, 2026, at 8:50 AM, Resident CR1 indicated that on August 6, 2026, he left the facility to go to an appointment. He explained that he reported to staff that he was going to his appointment and planned to return to the facility. Resident CR1 indicated that staff followed him and told him he was leaving the facility against medical advice and would be discharged . Resident CR1 indicated that he was frustrated with the service and just wanted to resolve the issue he was experiencing with his eyeglasses. He indicated that the facility staff attempted to have him sign paperwork that he was discharging against medical advice, but he refused to sign. Resident CR1 explained that when he arrived back at the facility, he contacted community support and was informed that he does not have to leave the facility. Resident CR1 indicated that multiple staff attempted to have him sign documentation that he was leaving against medical advice, but he refused to sign that documentation. Resident CR1 said that when the police arrived, he left the facility because he didn't want to have any issues with law enforcement. Resident CR1 indicated that he wanted to remain at the facility. A review of the medication administration record dated August 6, 2026, revealed an hour before the police arrived to remove the resident, the facility continued to provide care for Resident CR1. On August 6, 2026, at 5:00 PM, Resident CR1 received a 500 mg levetiracetam tablet for idiopathic epilepsy. A review of documentation provided by the facility and confirmed during the interview with local law enforcement, revealed there are pending charges against Resident CR1 for harassment: subjecting another to physical contact (making unwanted, intentional physical touch, like hitting, pushing, kicking, or grabbing with the specific intent to annoy, alarm, or harass someone) because he was witnessed pushing Employee 3, ADON. However, a review of the clinical record revealed no evidence Resident CR1 was evaluated to determine if he poses a risk to the safety of other residents following the incident on August 6, 2026. There was no documented evidence the physician assessed and confirmed that Resident CR1's behavior endangered the safety of individuals in the facility to justify a facility-initiated discharge. Further review of the clinical record revealed no evidence the facility provided Resident CR1 with a 30-day written notice of discharge outlining the reason for the transfer and his appeal rights. During an interview on August 26, 2026, at 12:30 PM, the above information was reviewed with the Nursing Home Administrator and Director of Nursing. The facility failed to permit Resident CR1 to remain in the facility, notified law enforcement and had the resident escorted from the facility. 28 Pa. Code 201.18 (b)(2) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3) Nursing services.

Based on a review of clinical records, the Resident Assessment Instrument (RAI) User's Manual and staff interviews, it was determined the facility failed to ensure the Minimum Data Set assessments (MDS) accurately reflected the clinical status of 3 of twenty residents reviewed (Residents 59, 45, and 66).Findings include: A clinical record review revealed Resident 59 was admitted on [DATE], with diagnoses including traumatic brain injury (an injury to the brain caused by an external force that can affect thinking, movement, and behavior), bipolar disorder (a mental health condition characterized by periods of elevated and depressed mood), and intellectual disability (limitations in mental functioning affecting learning and daily living skills). A review of the Medication Administration Record (MAR, a legal document that records medications and treatments administered to a resident) dated October 2025 revealed the resident received a one-time intravenous hydration infusion (IV, fluids delivered directly into a vein) of normal saline solution (a sterile saltwater solution used to replace fluids and electrolytes) totaling 1000 milliliters at a rate of 500 milliliters per hour on October 22, 2025. The infusion included micronutrients such as B-complex vitamins B1 200mg, B2 4 mg, B5 4 mg, B6 4 mg, B3 200 mg (a group of vitamins that support metabolism but do not provide calories), vitamin B12, zinc, magnesium, and calcium for hydration and wellness purposes. Resident 59's quarterly MDS dated [DATE], revealed Section K0520 (Nutritional Approaches) was coded yes for parenteral or IV feeding (nutrition delivered directly into the bloodstream), and Section K0710 (intake by artificial route) was coded to reflect intake by IV. The Resident Assessment Instrument (RAI) User's Manual, a reference guide used to properly code the MDS) Minimum Data Set Assessment (MDS a federally required standardized assessment used to evaluate a resident's condition and guide care planning) specifies that IV fluids administered for hydration or as a vehicle for medications are not to be coded as parenteral feeding. The infusion consisted of fluids and micronutrients only and did not include nutrients such as calories, protein, fat, or carbohydrates required to meet nutritional needs. The clinical record did not contain documentation to support that the IV therapy met criteria for nutritional support. Therefore, Sections K0520 and K0710 were coded inaccurately. Review of Resident 59's November 2025 MAR revealed a similar one-time IV hydration infusion administered on November 19, 2025, at 12:35 PM consisting of fluids and micronutrients, B complex vitamins, vitamin B12, zinc, magnesium, and calcium for hydration and wellness purposes The quarterly MDS for Resident 59 dated November 21, 2025, again coded Section K0520 and K0710 to reflect IV feeding. The clinical record did not support that the infusion qualified as nutritional support per the RAI criteria. These sections were coded inaccurately. A clinical record review revealed Resident 45 was admitted on [DATE], with diagnoses including type two diabetes (a condition in which blood sugar levels are elevated due to problems with insulin), muscle atrophy (loss of muscle mass), and vascular dementia (cognitive decline caused by reduced blood flow to the brain). A review of Resident 45's Medication Administration Record MAR, dated January 2026 revealed the resident received a physician-ordered, one-time intravenous hydration infusion on January 14, 2026, at 12:30 PM through an outside contracted infusion service. The infusion consisted of 0.9 percent normal saline solution (a sterile saltwater solution used to replace fluids and electrolytes) totaling 1000 milliliters, administered at a rate of 250 milliliters per hour via a peripheral IV (a small flexible tube inserted into a vein for short-term fluid or medication administration).The infusion also contained added micronutrients and supplements, including vitamin C, B-complex vitamins vitamin B12, zinc, magnesium, calcium, and amino acids (building blocks of protein used by the body for tissue repair), which were provided for hydration and general wellness purposes.A review of Resident 45's quarterly MDS dated [DATE], revealed Section K0520 (Nutritional Approaches) was coded yes to indicate the resident received parenteral or IV feeding during the seven-day look-back period.Additionally, Section K0710 (Intake by Artificial Route) was coded to indicate the resident received a portion of calories and fluids through an artificial route during the assessment period.The Resident Assessment Instrument (RAI) User's Manual specifies that IV fluids administered for hydration or as a vehicle for medications are not to be coded as parenteral feeding under Section K0520.The clinical record did not contain documentation to support that the IV infusion was used to provide nutrition, such as calories, protein, fat, or carbohydrates required to meet nutritional needs. Therefore, the coding of Sections K0520 and K0710 on the January 14, 2026, MDS was inaccurate. A clinical record review revealed Resident 66 was admitted on [DATE], with diagnoses including cerebral infarction (brain damage caused by loss of blood flow), protein calorie malnutrition (a condition in which the body does not receive enough calories and protein), and cognitive communication deficits (difficulty communicating due to impaired thinking processes). A review of the November 2025 MAR revealed the resident received a one-time intravenous hydration infusion on November 19, 2025, consisting of normal saline with added micronutrients including B-complex vitamins, vitamin B12, zinc, magnesium, and calcium. The quarterly MDS dated [DATE], coded Section K0520 as yes for parenteral or IV feeding and Section K0710 to reflect intake by artificial route. The infusion consisted of fluids and micronutrients only and did not include nutrients such as calories, protein, fat, or carbohydrates required to meet nutritional needs. The clinical record did not support that the IV infusion was used for nutritional feeding. Per the RAI User's Manual, this type of IV therapy does not meet criteria for coding under Section K. The MDS was coded inaccurately. Further review of the December 2025 MAR revealed an additional one-time intravenous hydration infusion administered on December 17, 2025, consisting of fluids and micronutrients. The quarterly MDS dated [DATE], again coded Section K0520 and K0710 to reflect IV feeding. The clinical record did not contain documentation supporting that the infusion met criteria for parenteral nutrition. These sections were coded inaccurately. During an interview with the facility's Nursing Home Administrator (NHA) on April 24, 2026, at 11:30 AM, the above findings were reviewed. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to consistently monitor residents' nutritional and hydration status to timely identify declines, implement individualized and less invasive interventions, and ensure clinical justification prior to initiating invasive interventions for three of twenty residents reviewed (Residents 59, 45, and 66). This deficiency is cited as past noncompliance.Findings include: A review of a facility policy entitled Weight Assessment and Interventions last reviewed by the facility on May 20, 2025, indicated each resident's weight will be monitored by the interdisciplinary team and intervene for undesirable weight loss. Any weight change of percent or more since the last weight assessment will be retaken for confirmation and if the weight is verified, nursing will immediately notify the Registered Dietitian. The threshold for significant unplanned and undesired weight loss will be based on 5 percent weight loss is significant and any change greater than in one month is severe, 7.5 percent weight loss is significant and any change greater than in three months is severe, and 10 percent weight loss is significant and any change greater than in six months is severe. A review of a policy entitled Early Interventions for Weight Loss Guidelines last reviewed by the facility on May 20, 2025, indicated that identification of unplanned, significant weight loss, especially in the case of greater than 5 percent in a thirty-day period, should lead to the implementation of appropriate nutrition interventions. Interventions should be discussed with the interdisciplinary team at the morning clinical meeting. A food first approach should be utilized when selecting an early intervention for unplanned weight loss. Early intervention include, but not limited to: focus on food preferences, appropriate food consistency snacks, fortified foods (foods enhanced to increase calories and protein), and meal tray extras, assistance with eating or assistive devices to increase independence, more liberalized diet to increase food and fluid variety, changing meal environment to remove distractions or barriers to intake, family involvement with visits or assistance at mealtimes, and assessment for depression and dementia. A clinical record review revealed Resident 59 was admitted to the facility on [DATE], with diagnoses that included traumatic brain injury (TBI, injury (a brain injury caused by an external force affecting thinking, movement, or behavior), bipolar disorder (a mental health condition with mood swings), and unspecified intellectual disabilities (limitations in intellectual functioning and daily living skills). A review of Resident 59's quarterly Minimum Data Set (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the residents Brief Interview for Mental Status (BIMS, 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 0-7 indicates severe cognitive impairment) score was 4, severe cognitive impairment. The resident required supervision and assistance with eating. A clinical record review revealed the registered dietitian completed a nutrition progress note on September 25, 2025, at 8:07 PM, which identified significant weight loss for Resident 59 exceeding five percent in one month and ten percent in six months. The note documented the following weights: September 24, 2025: 184.6 poundsAugust 25, 2025: 195.2 pounds, reflecting a 5.4 percent loss in one monthJune 3, 2025: 202.4 pounds, reflecting an 8.8 percent loss in three monthsMarch 3, 2025: 203.4 pounds, reflecting a 9.2 percent loss in six months The dietitian documented significant weight loss over thirty days and ninety days. At that time, Resident 59 received a regular diet with pureed textures, thin liquids, fortified foods with meals, Health Shakes, and ice cream with lunch and dinner. Fortified foods are foods enhanced to increase calories and protein, such as mashed potatoes, pudding, and hot cereal. Food intake averaged 26 to 100 percent at meals with Health Shakes (oral nutritional supplements used to provide additional calories and protein) and ice cream (initiated October 8, 2024) provided with lunch and dinner meals for nutrition support. The dietitian recommended increasing Health Shakes to all meals and obtaining weekly weights for four weeks to closely monitor the resident's weight trend and allow timely intervention. However, the clinical record failed to show that Health Shakes were ordered three times per day with meals until September 26, 2025, at 8:00 AM. Weekly weights after the dietitian's recommendation were recorded as follows: September 29, 2025: 184 poundsOctober 2, 2025: 186.2 poundsOctober 6, 2025: 183.3 poundsOctober 13, 2025: 194.6 poundsOctober 17, 2025: 183.4 pounds These weights continued to show fluctuation and did not demonstrate consistent stabilization after the significant weight loss was identified. A review of a Physician/Certified Registered Nurse Practitioner (CRNP) progress note dated October 16, 2025, at 11:53 AM, revealed Resident 59 had ongoing low fluid intake despite reported interventions. The CRNP documented the resident had recent weight loss, decreased appetite, recent falls, and a decreased sense of thirst. Interventions included encouraging fluids during meals, offering preferred beverages, and an order to increase oral (by mouth) fluid intake. However, the clinical record failed to contain consistent documentation that these oral hydration interventions were implemented or effective. The CRNP determined that intravenous (IV) hydration (fluid administered directly into a vein to treat or prevent dehydration) was appropriate to prevent further decline. The physical assessment noted continued weight loss, no swelling (edema), and no signs of fluid overload (excess fluid in the body). Staff reported no difficulty swallowing, nausea, or vomiting. A review of Resident 59's Medication Administration Record (MAR), (legal record of medications and treatments administered), revealed that on October 22, 2025, at 8:03 AM, six days after the CRNP identified the need, the resident received a one-time IV infusion. The infusion consisted of one thousand milliliters of normal saline (a sterile saltwater solution used to replace fluids) administered at a rate of five hundred milliliters per hour through a peripheral IV (a small tube inserted into a vein for short-term fluid administration). The infusion also included vitamins and minerals (micronutrients), including B-complex vitamins, vitamin B12, zinc, magnesium, and calcium. A subsequent dietitian assessment dated [DATE], noted continued significant weight loss, including a 5.2 percent loss over one month and an 8.8 percent loss over six months. The resident received a regular diet with pureed texture, fortified foods (foods enhanced to increase calories and protein), Health Shakes (oral nutritional supplements), and ice cream for additional caloric intake. Meal intake ranged from 51 to 100 percent, and the resident required staff assistance for eating. The dietitian documented a slight weight gain trend following increased oral supplementation and planned continued monitoring for weight stabilization.The clinical record failed to demonstrate that oral hydration and nutrition interventions were fully implemented, monitored for effectiveness, and exhausted prior to initiating IV hydration. In addition, the record failed to include laboratory data (blood tests used to assess hydration and electrolyte balance) to clinically support the need for IV hydration administered on October 22, 2025.Further review of CRNP progress notes dated November 13, 2025, December 11, 2025, and January 8, 2026, continued to document low fluid intake with similar findings and recommendations for IV hydration, despite limited documented evidence that oral hydration strategies were consistently implemented or evaluated for effectiveness.A review of subsequent MARs revealed the resident received additional one-time IV micronutrient infusions on November 19, 2025, December 17, 2025, and January 14, 2026, using the same solution and administration method.However, the clinical record failed to demonstrate that laboratory testing was obtained prior to these treatments to support a clinical need for IV hydration. Additionally, the record failed to show that individualized, less invasive nutritional and hydration interventions were attempted, evaluated, and found ineffective prior to repeated use of IV therapy. A review of Resident 45's clinical record revealed admission to the facility on June 22, 2022, with a diagnosis including type two diabetes (a condition causing high blood sugar), muscle wasting (loss of muscle mass), and vascular dementia (decline in thinking due to reduced blood flow to the brain). A review of Resident 45's quarterly assessment dated [DATE], revealed the residents Brief Interview for Mental Status (BIMS) score was 3, a score of 0-7 indicates severe cognitive impairment. The resident required set up or clean-up assistance with meals. A clinical record review revealed physician orders for a controlled carbohydrate diet with regular texture and thin liquids, Health Shake once daily with dinner, and a liquid protein supplement 30 milliliters daily for skin integrity.A review of the resident's weight record revealed the following:December 1, 2025: 135.6 poundsJanuary 1, 2026: 122.8 poundsJanuary 2, 2026 (reweigh): 124.2 poundsThese weights reflect a loss of 11.4 pounds, or 8.4 percent, in one month, which is considered significant. A dietitian progress note dated January 6, 2026, at 7:02 AM, confirmed the significant weight loss of 8.4 percent in one month. Meal intake ranged from 51 to 100 percent. The resident accepted the Health Shake but refused the liquid protein supplement, with zero percent intake documented. The dietitian recommended discontinuing the liquid protein supplement due to poor acceptance and initiating weekly weights for four weeks to closely monitor weight trends. The note also referenced thyroid testing, including TSH (thyroid stimulating hormone, a blood test used to evaluate thyroid function), with follow-up scheduled and recent adjustment to Levothyroxine (a medication used to treat thyroid conditions).A review of a Physician/Certified Registered Nurse Practitioner (CRNP) progress note dated January 8, 2026, at 9:49 AM, revealed the resident had persistent low fluid intake despite reported interventions, including encouragement of fluids during meals and offering preferred beverages. The record failed to contain consistent documentation supporting that increased oral fluid intake was implemented or effective. The CRNP noted the resident had recent weight loss, decreased appetite, recent falls, and decreased perception of thirst, and determined intravenous (IV) hydration (fluid administered directly into a vein to treat or prevent dehydration) was appropriate. The physical assessment noted continued weight loss with no signs of edema (swelling) or fluid overload. Staff reported no difficulty swallowing, nausea, or vomiting. A review of the Medication Administration Record revealed the resident received a one-time IV micronutrient infusion on January 14, 2026, at 12:30 PM. The infusion consisted of one thousand milliliters of normal saline (a sterile saltwater solution used to replace fluids) administered at a rate of 250 milliliters per hour through a peripheral IV (a small tube inserted into a vein for short-term treatment). The infusion included vitamins and minerals such as vitamin C, B-complex vitamins, vitamin B12, zinc, magnesium, calcium, taurine, glycine, folic acid, and glutamine. A review of a basic metabolic panel (a group of blood tests used to evaluate hydration status, kidney function, and overall health) collected on January 14, 2026, at 8:08 AM, and reported the same day at 5:14 PM, revealed the following results for Resident 45:Blood Urea Nitrogen (BUN), a test used to assess kidney function and hydration status, was 13 milligrams per deciliter, which is within the normal range of 6 to 20.Creatinine, a blood test used to evaluate kidney function, was 0.6 milligrams per deciliter, which is within the normal range of 0.5 to 1.0.Estimated Glomerular Filtration Rate (eGFR), a calculation used to determine how well the kidneys filter waste, was 89 milliliters per minute, which is within normal limits.Sodium, an electrolyte that helps regulate fluid balance, was 142 millimoles per liter, which is within the normal range of 135 to 146.Potassium, an electrolyte important for heart and muscle function, was 4.7 millimoles per liter, which is within the normal range of 3.5 to 5.1.Chloride, an electrolyte that helps maintain fluid and acid balance, was 104 millimoles per liter, which is within the normal range of 98 to 107.Glucose, a measure of blood sugar, was 145 milligrams per deciliter, which is above the normal range of 70 to 120.Albumin, a protein used as an indicator of nutritional status, was 4.1 grams per deciliter, which is within the normal range of 3.8 to 5.0.Total protein, a measure of overall protein levels in the blood, was 7.3 grams per deciliter, which is within the normal range of 6.0 to 8.3.Prealbumin, a test used to assess short-term nutritional status, was 22 milligrams per deciliter, which is within the normal range of 18 to 45.All laboratory values were within normal limits, except for an elevated glucose level.The MAR review revealed the micronutrient infusion was administered on January 14, 2026, at 12:30 PM. The facility could not provide documented evidence of weekly weights being completed on January 9, 2026, January 16, 2026, January 23, or January 30, 2026, as recommended by the RD to monitor weight after a significant weigh loss from December 1, 2025, to January 2, 2026.The record failed to demonstrate that less invasive nutritional and hydration interventions were attempted and evaluated prior to initiating IV therapy. A clinical record review revealed Resident 66 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients), protein calorie malnutrition (lack of adequate protein and calories), and cognitive communication deficits (occurs when a person's ability to communicate effectively is compromised due to impairments in cognitive processes such as attention, memory, and executive functions, rather than a direct problem with language or speech). A review of Resident 66's annual MDS assessment dated [DATE], revealed that the residents Brief Interview for Mental Status score was 15, indicating intact cognition. The resident was not receiving a mechanically altered diet, but received a therapeutic diet, and required setup or clean-up assistance with meals. A review of Resident 66's weight record revealed the following:October 1, 2025: 134.8 poundsOctober 7, 2025: 128.8 poundsThis reflects a loss of 6 pounds within one week, which is a significant and rapid weight decline.A dietitian progress note dated November 6, 2025, at 8:02 PM, completed thirty-one days after the initial weight loss, documented continued concern. The note referenced a weight of 127.7 pounds obtained on November 1, 2025, which was later crossed out by nursing staff on November 12, 2025. Based on the available data, the dietitian identified a weight loss of 7.1 pounds, or 5.3 percent, over one month.Additional weight comparisons included:October 1, 2025: 134.8 pounds, reflecting a 5.3 percent loss over one monthAugust 5, 2025: 133.4 pounds, reflecting a 4.3 percent loss over three monthsMay 1, 2025: 133.4 pounds, reflecting a 4.3 percent loss over six monthsThe dietitian noted the resident's weight was considered underweight for advanced age and identified significant weight loss over thirty days. At that time, the resident was receiving a regular diet with regular texture and thin liquids, with meal intake ranging from fifty-one to one hundred percent. Recommendations include providing fortified foods (food enhanced to increase calories and protein) with all meals and obtaining weekly weights for four weeks to monitor for stabilization or gain.The clinical record failed to demonstrate that these interventions were implemented timely following the initial significant weight loss identified in early October 2025. A review of a Certified Registered Nurse Practitioner (CRNP) progress note dated November 13, 2025, at 11:28 AM, documented increased cognitive decline and continued low fluid intake. Interventions included offering fluids, encouraging intake, and providing preferred beverages. Despite these efforts, the resident's intake remained inadequate, and intravenous (IV) hydration (fluid administered directly into a vein to treat or prevent dehydration) was determined to be appropriate. The physical assessment noted no swelling (edema) and no signs of fluid overload. Staff reported no difficulty swallowing, nausea, or vomiting.A review of the Medication Administration Record (MAR), the legal record of treatments administered, revealed the resident received a one-time IV micronutrient infusion on November 19, 2025, at 12:30 PM, six days after the CRNP identified the need. The infusion consisted of one thousand milliliters of fluid administered at a rate of one thousand milliliters per hour through a peripheral IV (a small tube inserted into a vein for short-term treatment) and included vitamins and minerals such as B-complex vitamins, vitamin B12, zinc, magnesium, and calcium. Resident 66's clinical record failed to demonstrate that less invasive nutritional and hydration interventions were implemented, monitored, and determined to be ineffective prior to initiating IV therapy.During an interview on April 23, 2026, at 12:45 PM, the Director of Nursing stated that residents with decreased intake were referred to the CRNP to determine if IV micronutrient therapy was appropriate. During an interview on April 24, 2026, at 11:00 AM, the Nursing Home Administrator confirmed that weight monitoring was not completed timely, and that less invasive nutritional and hydration interventions should have been attempted prior to implementing IV therapy. This deficiency was cited as past non-compliance. The facility's corrective action plan included the following: Residents that were receiving IV hydration were reviewed and the physician/NP (nurse practitioner) clarified orders to ensure clinical indication, evidence of less invasive measures attempted, and duration and monitoring parameters. Residents were assessed for oral intake capacity, swallow status, cognitive ability to participate, and reversible causes (i.e. urinary tract infection, medications, constipation). Residents who received IV therapy in the last three months were reviewed to ensure decline in nutrition/hydration status was documented and appropriate and that the least invasive interventions were implemented and documented. To prevent future occurrences, the facility's licensed nursing staff were re-educated on the facility's hydration policy, least restrictive intervention standards, documentation expectations, and clinical criteria for use of IV hydration. To monitor and maintain ongoing compliance, the DON or designee audited the use of IV therapy for appropriate rationale for IV implementation or the least invasive interventions were attempted and failed, and documentation weekly for two weeks, then monthly for four weeks with results reported monthly to QAPI (Quality Assurance and Performance Improvement, a data-driven framework to maintain and enhance care quality in healthcare facilities) Committee meetings. The facility's compliance date was February 19, 2026, and completion of corrective action plan noted above was confirmed during the survey ending April 24, 2026.28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on observations, resident and staff interviews, clinical record review, and review of facility policy, it was determined the facility failed to provide a comfortable and homelike environment by failing to maintain acceptable sound levels from the resident call bell system on one of three floors observed (Fourth Floor), which resulted in ongoing excessive noise that disrupted rest and comfort for three residents (Residents 6, 61, and 73).Findings include: A review of the policy titled Call System, Resident last review May 20, 2025, revealed residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. An interview with Employee 1 Nurse Aide, on April 21, 2026, revealed the call bell system malfunctioned on April 20, 2026, and, although repaired, remained set only at the loudest volume. Employee 1 stated staff notified maintenance of the excessive loudness. A review of the clinical record revealed Resident 6 on October 9, 2023, with a diagnosis to include Rheumatoid arthritis (an autoimmune disease that primarily affects the joints causing pain and swelling and stiffness) and Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period). A review of the quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 2, 2026 revealed that Resident 6 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 13-15 indicates cognition is intact). During an interview on April 21, 2026, at 11:30 AM, Resident 6 reported the call bell noise during the night was extremely loud and disruptive to sleep, stating, I got no sleep, that thing is so loud. A clinical record review revealed Resident 61 was admitted on [DATE], with diagnoses including orthopedic aftercare following surgical amputation (post-surgical recovery focused on healing and preventing complications after removal of a body part) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period). A review of the quarterly MDS dated [DATE], revealed that Resident 6 was cognitively intact with a BIMS score of 13. During an interview on April 21, 2026, at 11:45 AM, Resident 61, whose room was located directly across from the nurse's station, reported repeated sleep disruption due to the call bell speaker outside the room, stating, I didn't sleep. Every time the bell went off, it woke me up. The speaker is right outside my door. That bell rang all night. An observation on April 22, 2026, at 9:00 AM revealed the call bell system on the Fourth Floor continued to operate at the loudest setting, indicating the condition remained uncorrected. A clinical record review revealed Resident 73 was admitted on [DATE], with diagnoses including poly-osteoarthritis (degenerative joint disease causing pain and stiffness in multiple joints) and lack of coordination (impaired ability to perform smooth, controlled movements). A review of the MDS dated [DATE], indicated Resident 73 was cognitively intact with a BIMS score of 14. During an interview on April 22, 2026, at 10:39 AM, Resident 73 reported the call bell noise was amplified (increased in volume) when wearing hearing aids, resulting in discomfort. The resident stated I take the hearing aids out at night, so it wasn't awful, but during the day it is terribly loud, I don't want to take them out. I won't be able to hear anything else. An interview with the Nursing Home Administrator on April 22, 2026, at 12:00 PM was conducted to review the above findings related to the facilities failure to provide a homelike environment for residents including maintaining sound levels that do not interfere with residents' comfort, rest, or ability to sleep. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident out of 20 residents reviewed (Resident 79).Findings include: Review of the facility Restorative Nursing Services Policy, last reviewed May 20, 2025, revealed that residents will receive restorative nursing care (RNP) as needed to help promote optimal safety and independence. Review of the policy revealed that the resident's restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. A clinical record review revealed Resident 79 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a chronic joint condition in which the protective cartilage breaks down, resulting in pain, stiffness, and decreased movement) and abnormal posture. A review of Resident 79's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 9, 2026, revealed that Resident 79 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 through 15 indicates moderate cognitive impairment). A review of the clinical record indicated physical therapy services were provided from March 12, 2026, through April 7, 2026. A review of the physical therapy Discharge summary dated [DATE], indicated the resident was able to ambulate 10 to 25 feet with the assistance of one staff person using a front-wheeled walker (a mobility device with wheels that assists with balance and walking). Discharge recommendations included continued use of an assistive device, assistance with activities of daily living (routine self-care tasks such as bathing, dressing, and toileting), and implementation of a restorative nursing program. The discharge summary indicated restorative nursing program interventions were developed and communicated to the Interdisciplinary Team (IDT, a group of healthcare professionals responsible for coordinating resident care), including ambulation of approximately 15 feet with a front-wheeled walker with assistance of one staff person to maintain functional mobility and prevent decline. A review of the Resident 79's care plan, in effect through the survey end date of April 24, 2026, identified a focus area for impaired range of motion with an intervention for active range of motion exercises (movements performed by the resident using their own muscle strength to maintain joint flexibility) to the right upper extremity for at least 15 minutes. A review of Resident 79's electronic task report (a system-generated record that tracks scheduled and completed care tasks) and the Documentation Survey Report for April 2026 revealed multiple shifts in which restorative nursing interventions were not documented as completed. Review of the clinical record revealed no consistent documentation to support that restorative nursing services, including ambulation and range of motion exercises, were provided as planned. An interview with Resident 79 on April 22, 2026, at 10:00 AM indicated the resident was upset due to the lack of consistent restorative nursing services. The resident reported a desire to participate in therapy and restorative nursing to improve mobility and return home. The resident stated that certain staff members assist with the task but often staff are busy and do not help her. During an interview on April 23, 2026, at 11:30 AM, the Director of Nursing reviewed the above findings and was unable to provide documented evidence that the facility consistently implemented the restorative nursing program for Resident 79 as planned. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa Code 211.12(c)(d)(5) Nursing services.

Based on observations, a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure the environment remained free from potential accident hazards related to the unsafe storage and access of medications for one of three nursing units reviewed (Unit 4) and for one of 20 residents sampled (Resident 58).Findings included: A review of the facility policy titled Administering Medications, last reviewed May 20, 2025, revealed it is the facility policy that medications are administered in a safe and timely manner and as prescribed. A review of the facility policy titled Self-Administration of Medications, last reviewed May 20, 2025, revealed it is the facility policy that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in a resident's room, the medication of residents permitted to self-administer is stored on a central medication cart or in the medication room. A clinical record review revealed Resident 58 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels) and muscle weakness. The clinical record revealed no documented assessment indicating Resident 58 was evaluated and approved to self-administer medications. Review of physician orders revealed an order dated November 5, 2025, for Ipratropium Bromide 0.03% nasal solution (a prescription medication used to relieve nasal symptoms such as runny nose), to be administered once daily in each nostril. Observation conducted on April 22, 2026, at 09:30 AM revealed a bottle of Ipratropium Bromide nasal spray and an opened bottle of Tums (an over-the-counter medication containing calcium carbonate used to relieve heartburn) located on the resident's bedside table and accessible to the resident. Interview with Resident 58 at the time of the observation revealed the resident used the medications as needed and confirmed staff left the medications at the bedside for his use. Review of the clinical record revealed no physician order for the over-the-counter Tums observed at the bedside. During an interview on April 22, 2026, at 11:00 AM, the Nursing Home Administrator reviewed the above findings, including that nursing staff left medications accessible at the bedside without evidence the resident had been assessed or approved to self-administer. The facility failed to assess the resident's ability to safely self-administer medications and to ensure medications were securely stored to prevent the potential for improper use, incorrect dosing, or access by other residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of controlled drug shift count records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled medication records for one of two medication carts observed.Findings include: A review of the facility policy titled Controlled Substances, medications regulated by federal and state law due to their potential for misuse, dependency, or diversion. Accurate counting and documentation are required to ensure accountability and to prevent loss or misuse) last reviewed May 21, 2025, revealed controlled medications are counted at the end of each shift. The oncoming licensed nurse and the off-going licensed nurse are required to complete the count together. The oncoming licensed nurse signs the controlled substance record to acknowledge receipt, and the off-going licensed nurse signs to verify the count was completed and correct. A review of the facility Controlled Drug Key Exchange Audit for the fourth floor back hall nursing unit (Rooms 408 to 416) medication cart revealed that on April 20, 2026, the evening shift off-going nurse failed to sign the controlled substance record to verify the narcotic count was completed and correct. A review of the facility Controlled Drug Key Exchange Audit for the fourth floor front hall nursing unit (Rooms 401 to 408) medication cart revealed that on April 20, 2026, the evening shift off-going nurse failed to sign the controlled substance record to verify the narcotic count was completed and correct. During an interview on April 22, 2026, at 9:10 AM, Employee 2, a Licensed Practical Nurse (LPN), confirmed that the controlled substance records for both the fourth floor front hall medication cart and the fourth floor back hall medication cart were not signed by the off-going nurses on the identified date. During an interview on April 21, 2026, at 12:00 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reviewed the above findings and confirmed the facility did not demonstrate consistent implementation of its policy requiring completion and verification of controlled substance counts at shift change. 28 Pa. Code 211.10(a) Resident Care Policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa Code 211.9 (c)(k) Pharmacy services. 28 Pa Code 211.5(f)(x) Clinical records.

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure timely physician notification of clinically significant abnormal laboratory results for one of 20 residents reviewed (Resident 87). This deficiency is cited as past non-compliance.Findings include: A review of the facility policy entitled Lab and Diagnostic Testing Clinical Protocol, last reviewed May 20, 2025, indicated the physician will identify, and order diagnostic testing and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing sources will report test results to the facility. When test results are reported to the facility, a nurse will first review the results. Before contacting the physician, the person who is to communicate the results to a physician will gather, review, and organize the information and be prepared to discuss the following: the individuals current condition and details of any recent changes in status (i.e. vital signs and mental status); major diagnoses, allergies, current medications, any recent pertinent lab work; why the lab work and diagnostic tests were obtained; how test results may relate to the individual's current conditions and treatments; and any concerns and questions the physician will be expected to address regarding the resident. Documentation regarding notification will be recorded in the resident's medical record. A review of the clinical record revealed Resident 87 was admitted on [DATE], with diagnoses that included diabetes (a chronic condition affecting the body's ability to regulate blood sugar), dysphagia (difficulty swallowing), and hypokalemia (a condition in which the potassium level in the blood is lower than normal; potassium is an electrolyte that supports heart, muscle, and nerve function). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 14, 2025, revealed that Resident 87 had moderately impaired cognition with a BIMS score of 12 (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 12-15 indicates intact cognition). A review of physician orders dated December 11, 2025, at 6:38 PM, revealed an order for potassium chloride extended-release (a medication used to increase potassium levels in the blood) 20 milliequivalents (mEq) by mouth two times daily, and spironolactone 25 milligrams (mg), a potassium-sparing diuretic (a medication that removes excess fluid while retaining potassium), one time daily related to chronic pulmonary edema (primarily caused by fluid accumulation in the lungs). A review of laboratory results from a complete metabolic panel (CMP, a blood test that evaluates organ function, blood sugar, and electrolyte balance) obtained December 12, 2025, revealed the following abnormal values: Blood Urea Nitrogen (BUN, a test measuring waste products in the blood to assess kidney function): 39 milligrams per deciliter (mg/dL), with a normal range of 6-20 mg/dL (elevated)Creatinine (a blood test used to evaluate kidney function): 1.4 mg/dL, with a normal range of 0.5-1.0 mg/dL (elevated)Estimated Glomerular Filtration Rate (eGFR, a calculation used to determine how well the kidneys filter waste): 37 milliliters per minute (mL/min), with a normal value of greater than or equal to 60 mL/min (reduced kidney function)Potassium (an electrolyte essential for heart and muscle function): 5.2 millimoles per liter (mmol/L), with a normal range of 3.5-5.1 mmol/L (elevated)Chloride (an electrolyte that helps maintain fluid and acid-base balance): 97 mmol/L, with a normal range of 98-107 mmol/L (low)The clinical record failed to reveal documented evidence that licensed nursing staff notified the physician of the above abnormal laboratory results obtained on December 12, 2025, specifically the elevated potassium level in the presence of medications that increase potassium. A review of Resident 87's nursing progress note dated December 14, 2025, at 6:23 PM, revealed the resident's daughter reported the resident was tired and not herself and noted increased confusion. The RN supervisor was notified; however, there was no documented evidence that the physician was notified of the prior abnormal laboratory findings or the change in condition. A review of a progress note dated December 15, 2025, at 1:33 PM, revealed the Certified Registered Nurse Practitioner (CRNP) evaluated the resident and ordered repeat laboratory testing for December 16, 2025. A review of a nursing progress note dated December 16, 2025, at 1:34 PM, revealed the laboratory reported a critically high potassium level of 7.4 mmol/L (critical value indicating severe hyperkalemia, which is dangerously high potassium that can cause life-threatening heart rhythm disturbances). The note indicated the resident had increased confusion and complaints of crushing pain at the base of the neck. The physician was notified at that time and ordered immediate transfer to the emergency room. A review of hospital records revealed Resident 87 was admitted with a diagnosis of hyperkalemia (a condition defined as potassium levels above the normal range, which can impair heart function and may lead to cardiac arrest if untreated). A review of the Medication Administration Record (MAR, a legal document that records medications administered to a resident) dated December 11 through December 16, 2025, revealed the resident continued to receive potassium supplementation and spironolactone as ordered despite the elevated potassium level identified on December 12, 2025. During an interview on April 23, 2026, at 10:00 AM, the Director of Nursing confirmed the facility failed to notify the physician of the abnormal potassium level obtained on December 12, 2025, and acknowledged the continued administration of potassium-increasing medications contributed to the critically elevated potassium level on December 16, 2025. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: All residents' labs and diagnostic studies were reviewed during morning interdisciplinary team meeting and again at stand-down meeting to identify any outstanding labs not followed by the physician and for documentation not in place of notification of the resident's responsible party (RP). To prevent future occurrences, the facility's licensed nursing staff were re-educated on the facility's policies and procedures related to the lab process. To monitor and maintain ongoing compliance, audits will be performed by nursing staff or designee to ensure documentation is completed. The audit will be completed three times per week for four weeks, then weekly for four weeks with results reported monthly to QAPI (Quality Assurance and Performance Improvement, a data-driven framework to maintain and enhance care quality in healthcare facilities) Committee meetings. The facility provided evidence that corrective actions were implemented, including re-education of licensed nursing staff on laboratory review and physician notification requirements, implementation of interdisciplinary laboratory review processes, and initiation of routine audits to ensure compliance. The facility's date of compliance was April 11, 2026. Verification of implementation and ongoing monitoring was confirmed during the survey ending April 24, 2026. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve resident complaints and grievances expressed during Resident Council meetings and written grievances, including those voiced by for two of ten residents reviewed. (Residents 1 and 2). Findings include:A review of the facility's Grievance Policy last revised on May 27, 2025, revealed that the resident has the right to voice grievances to the Center or other agency or entity (for example the State Ombudsman) that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The Nursing Home Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. A review of the Resident Council meeting minutes dated August 28, 2025, revealed repeated concerns that call bells were not being answered timely. A review of a written grievance from Resident 1, dated August 28, 2025, revealed that the resident stated she had to wait a long time for staff to respond to the call bell to meet her needs. The documented facility action was to conduct call bell audits. Resident 1 refused to sign the grievance as resolved, stating I am still waiting too long. Facility call bell audits were conducted from August 29, 2025, through September 1, 2025, and the grievance was marked by the NHA as completed and resolved on September 2, 2025. During an interview on September 3, 2025, at 11:00 AM, Resident 1 (who is cognitively intact, able to understand and communicate clearly) stated that staff response times to her call bell continued to be greater than 30 minutes on the second and third shifts. She reported she had voiced grievances both verbally and in writing at the August 2025 Resident Council meeting and remained unsatisfied with the facility's response. During an interview on September 3, 2025, at 11:15 AM, Resident 2 (also cognitively intact) stated he regularly waited longer than 30 minutes for staff to respond to his call bell. He reported that he requires the assistance of two staff members and his roller walker to ambulate to the bathroom and that he recently experienced a bowel incontinence episode because staff did not answer his call bell in time. During an interview on September 3, 2025, at 11:30 AM, the NHA and Director of Nursing (DON) acknowledged there was no documented evidence of completed resolutions for grievances raised during Resident Council meetings or for verbal complaints. 28 Pa. Code 201.18 (b)(1)(3) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10 (d) Resident Care policies.

Based on clinical record review and resident and staff interviews, it was determined the facility failed to ensure a resident was invited to participate in the care planning process for one of 19 residents reviewed (Resident 42). Findings include: A clinical record review revealed Resident 42 was admitted to the facility on [DATE], with diagnosis to include vascular dementia (reduced blood flow to the brain leading to cognitive decline) and polyosteoarthritis (inflammation and pain of five or more joints of the body). A review of the annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 7, 2025, revealed that Resident 42 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 cognitively intact). During an interview on June 17, 2025, at 10:15 AM, Resident 42 stated she has not been invited to participate in the care planning process for development of her comprehensive person-centered care plan or attend any care plan meetings. A further review of the clinical record revealed no documented evidence that a care plan conference had been conducted since November 20, 2024. The clinical record revealed no documentation that Resident 42 had been invited to participate in the development or review of her comprehensive care plan. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on June 18, 2025, at 1:38 PM, both confirmed there was no documentation to show that a care plan conference had been held for Resident 42 since November 2024 or that Resident 42 had been invited to participate in the care planning process. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 19 residents reviewed (Resident 18). Findings include: A review of Resident 78's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Depression. Resident 18 had been newly diagnosed on [DATE] with Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on June 16, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator on June 18, 2025, at 1:00 p.m., confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, and staff interview, it was determined the facility failed to consistently implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for one resident out of four residents sampled for pressure ulcer care (Resident CR1) resulting in the worsening of a Stage 2 pressure ulcer to an unstageable pressure injury, constituting actual harm. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of the facility policy titled Prevention of Pressure Injuries, provided on May 1, 2025, indicated the facility will review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The facility will inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living) and reposition the resident as indicated on the care plan. The facility will reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team and choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Additionally, monitoring of area(s) will include evaluation, report, and documentation of potential changes in the skin, and a review of interventions and strategies for effectiveness on an ongoing basis. A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), 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), and need for assistance with personal care. A review of Resident CR1's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 30, 2025, revealed that Resident CR1 was severely cognitively impaired with a BIMS score of 5 (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 0-7 indicates severe cognitive impairment), and required total staff assistance for activities of daily living, rolling in bed, and transfers; and was moderately at-risk for the development of pressure ulcers and injuries. Section M: Skin Conditions, indicated that Resident 18 had a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose or fat tissue is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) upon admission to the facility. According to the MDS the resident utilized an indwelling urinary catheter but was always incontinent of bowels. A review of the resident's care plan initiated March 25, 2025, identified a focus area related to skin integrity with planned interventions which included application of protective barrier cream after incontinent episodes and as needed, assist resident with turning and repositioning as needed, complete skin inspection every 7 days and as needed, complete wound evaluation to monitor the progress of the resident's skin condition, encourage/assist resident as needed to elevate heels off the mattress, pressure reducing air cushion to chair, and provide treatments as per physician orders. A review of Resident CR1's clinical record revealed an initial wound evaluation dated March 25, 2025, at 7:28 PM, which revealed the resident was admitted to the facility with a Stage 2 pressure ulcer on the sacrum that measured 2 cm x 2 cm x < 0. 1cm with no drainage and no odor present in the wound bed. The peri wound (skin area surrounding the wound) appearance was red in color. Review of a Skin and Wound note dated March 26, 2025, at 1:57 PM, completed by the wound care consultant, indicated the pressure area was on Resident CR1's right intergluteal fold (the vertical groove between the buttocks). The wound was classified as a stage 2 that measured 0.5 cm x 0.4 cm x 0.1 cm, was 100% epithelialized (entire surface of wound is covered by new skin tissue) with scant amount of serous drainage (clear, thin, watery fluid that is a normal part of the healing process). Treatment recommendations were to cleanse with soap and water, pat dry; apply Renew Peri Protect (specific barrier cream used to protect the skin from moisture) to the base of the wound every shift and as needed, provide swift incontinence management, provide an alternating air/low air loss mattress for pressure redistribution, and provide ongoing turning/repositioning precautions. Review of a Skin and Wound note dated April 2, 2025, at 2:06 PM, completed by the wound care consultant, indicated the stage 2 pressure area on the right intergluteal fold measured 0.5 cm x 0.4 cm x 0.1 cm and continued to be 100% epithelialized with a scant amount of serous drainage. Treatment recommendations included to cleanse with soap and water, pat dry, apply Renew Peri Protect to the base of the wound every shift and may be applied after each incontinence episode, provide swift incontinence management, keep resident off his bottom as resident will allow, and turn the patient side to side as tolerated. Despite these interventions being documented in wound care recommendations and the resident's care plan, a review of the Treatment Administration Records (TAR) for March and April 2025 failed to reveal documentation that Renew Peri Protect was ordered or applied as recommended by the wound care consultant on March 26, 2025, and April 9, 2025. Additionally, review of Resident CR1's Documentation Survey Report v2 (reports that capture care-related tasks completed by nurse aides) for March and April 2025 did not show evidence that staff consistently turned and repositioned the resident as per the plan of care and wound consultant's instructions. Review of Skin and Wound note dated April 9, 2025, at 2:06 PM, completed by the wound care consultant, documented the right intergluteal fold wound significantly worsened and spread across the sacral region. The pressure wound was now classified as an unstageable wound (type of wound where the base of the wound is obscured by slough, a yellow/white material consisting of dead cells or eschar, a dry, hard, leathery dead tissue in the wound bed, making it impossible to determine the true depth and stage of the wound) measuring 7.5 cm x 2.5 cm x 0.2 cm. The wound base was 40% slough with a moderate amount of serous drainage. Treatment recommendations included application of Renew Peri Protect every shift and apply after each incontinence episode, increase frequency of incontinence management due to new onset of diarrhea, keep off bottom, and turn the resident side to side every 2 hours and as needed. Although the wound had significantly declined, no new or intensified treatment interventions were initiated beyond reiterating the prior recommendations. Skin inspections were documented on April 1, 2025, and April 8, 2025, however, there were no wound measurements recorded for Resident CR1's sacral pressure area to evaluate whether the pressure ulcer was healing, worsening, or remaining unchanged. Facility policy indicated that wounds would be monitored to determine any potential changes. The lack of consistent wound measurements had the potential to prevent accurately evaluating the effectiveness of the treatment plan and adjusting interventions as necessary. Interview with the Director of Nursing on May 1, 2025, at approximately 12:45 PM, confirmed the facility could not provide evidence the treatment interventions ordered by the wound care consultant were implemented, including use of the barrier product or that new treatment interventions were developed after the decline in the wound was identified. The facility could not provide evidence of a consistent turning and repositioning schedule or that facility staff thoroughly evaluated Resident CR1's sacral pressure ulcer for worsening and/or improvement. There was no evidence the worsening of the wound was met with an updated plan of care or intensified interventions. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to complete a comprehensive nutritional assessment and monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement appropriate interventions to address weight loss for two of three residents reviewed for nutritional status and weight loss (Residents CR1 and A1). Findings included: A review of a facility policy entitled Nutritional Assessment last revised October 2024, revealed that the Registered Dietitian (RD), in conjunction with nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: usual body weight, current height and weight, a description of the resident's usual intakes, history of reduced appetite or progressive weight loss or gain prior to the resident's admission, current clinical conditions and recent events that may have affected a resident's nutritional status, general appearance - a description of the resident's overall appearance, usual meal and snack patterns, food preferences and dislikes (including flavors, textures, and forms), preferred portion size. Additionally, the assessment will include a review of prescribed medications that may affect nutrient absorption, appetite, level of consciousness, and/or gastrointestinal function, a review of laboratory results to assess fluid and electrolyte balance, an estimation of calorie, protein, and fluid needs, and an assessment of whether the resident's current intake is adequate to meet his or her nutritional needs. Further review of a facility policy entitled Weight Assessment and Intervention last revised by March 2022, indicated that in one month any unplanned/undesired significant weight chance of 5% or more since the last weight assessment is significant and greater than 5% is severe and any undesirable weight change is evaluated by the dietitian, physician, and multidisciplinary team to develop interventions to stabilize/improve the residents' weight. A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), weakness, and dependance on supplemental oxygen. Review of the resident's weight documentation revealed that on March 7, 2025, the resident weighed 123 pounds with a height of 65 inches, resulting in a Body Mass Index (BMI) of 20.6 (a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements) of 20.6 within ideal body weight. Further review of Resident CR1's weight record revealed the following weights: March 12, 2025, at 11:51 AM - 121.8-lbs. March 20, 2025, at 12:37 PM - 110.9-lbs., This represented a weight loss of 10.9 pounds or 8.9% in one week, and a total loss of 12.1 pounds or 9.8% since admission, which constituted severe and significant weight loss. No additional weights were recorded in Resident CR1's clinical record. A review of Resident CR1's Survey Documentation Report (a report that summarizes the recoded tasks performed by nurse aides) dated March 2025, revealed the resident's average meal intakes for breakfast, lunch, and dinner was approximately 31.4 percent. Review of the resident's Survey Documentation Report for March 2025 showed an average meal intake of approximately 31.4% across breakfast, lunch, and dinner. Progress notes dated March 25, 2025, at 11:01 AM, indicated the resident was transferred to the hospital due to altered mental status and hematuria (blood in urine). Hospital records dated March 25, 2025, at 4:41 PM, documented that the resident appeared extremely malnourished, exhibited signs of severe dehydration (loss of fluid in the body) and hypotension (low blood pressure), and was subsequently placed on hospice care. Further review of the clinical record revealed no documentation that a comprehensive nutritional assessment was completed by the RD upon admission, nor was there evidence that the resident's attending physician or responsible party (RP) had been notified of the resident's poor intake or progressive weight loss. An interview conducted with the facility's RD, in the presence of the Nursing Home Administrator (NHA), on April 8, 2025, at 10:45 AM, confirmed that a comprehensive nutritional assessment should have been completed within 72 hours of admission but was not completed for Resident CR1. The RD also confirmed that no interventions were initiated to address the resident's poor intake or significant weight loss. The NHA reported the prior RD had worked at the facility through February 28, 2025, and that a Certified Dietary Manager (CDM) provided temporary coverage from March 1 through March 9, 2025. The NHA acknowledged that a CDM is not qualified to complete comprehensive nutrition assessments and confirmed the facility did not employ a qualified nutrition professional during that period to fulfill this responsibility. A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Barrett's esophagus ( a condition in which tissue that is similar to the tissue lining in the intestines changes or replaces the lining of the esophagus which is the tube that transports food from the mouth to the stomach) without dysplasia (a precancerous condition), malignant neoplasm (cancerous tumors) and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). A review of the resident's comprehensive person-centered plan of care initiated December 7, 2023, and revised November 5, 2024, indicated that the resident was at risk for nutritional deficits due to diagnoses and required a therapeutic diet. Interventions included periodic weight monitoring, evaluation and notification of significant weight changes to the RD, physician, and family, provision of nutritional supplements as ordered, and the use of meals and snacks tailored to the resident's preferences and functional needs. A review of the resident's quarterly Nutrition Risk Assessment/Full - V4 assessment completed by the facility's RD dated January 29, 2025, at 11:51 AM, documented the resident needed increased nutrient needs related to cancer diagnosis, assist with meals to promote po (oral) intake, need verbal cues, and continue to use finger foods as available. Also, the RD noted to continue to monitor monthly weights per protocol with a goal to maintain weight stability, tolerate diet, adequate hydration, meet estimated needs, and skin integrity and adjust diet regimen prn (as needed). A review of Resident A1's weight record revealed the following recorded weights: January 6, 2025, at 1:56 PM, weight was 156.4 -lbs. February 1, 2025, at 11:45 AM, weight was 156.8 - lbs. March 3, 2025, at 3:11 PM, weight was 143.3 - lbs. March 4, 2025, 2:06 PM, weight was 145.2 - lbs. April 1, 2025, at 2:05 PM, weight was 146.4 - lbs. Further review of Resident A1's weight record revealed that he had a significant weight loss of 11.6 - lbs. or 7.4% in 30-day (February 1, 2025, through March 4, 2025). A review of a weight change note completed by the RD eighteen (18) days post weight loss on March 17, 2025, at 11:33 AM, indicated that weights were reviewed and identified a significant loss of 7.6% in 30 days. History of colon cancer and Barrett's esophagus. Diet order regular/regular texture/thin liquids with intake for meals is 50-100% and occasional intakes less than 50%. Lactose intolerance noted. Most recent labs from March 12, 2025, reviewed and medications reviewed. Comfort measures noted with weight stability desired. The RD's note confirmed the weight loss and stated the resident's physician and RP had been notified and that the plan was to continue monitoring and follow up with the interdisciplinary team. However, there was no evidence that additional or revised nutritional strategies were developed and implemented at the time of the initial weight loss. During an observation of the third-floor dining room on April 8, 2025, at 12:10 PM, Resident A1 was observed eating rice and meatballs with his hands. The resident scooped food with his hands, and food was observed falling before reaching his mouth. Interview with the Director of Nursing (DON) on April 8, 2025, at 1:00 PM, revealed that Resident A1 prefers to feed himself and often declines staff assistance. The DON confirmed the resident would benefit from the use of finger foods but acknowledged this intervention, which was part of the resident's care plan, was not being consistently implemented. Further interview with the DON confirmed that the facility failed to identify the resident's significant weight loss in a timely manner and failed to initiate nutritional interventions to address the weight loss or reinforce the use of care-planned accommodations, such as finger foods, to support the resident's independence and nutritional intake. 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of clinical records, document review, and resident and staff interviews, it was determined that the facility failed to provide an environment free from accident hazards to prevent potential incidents for one resident (Resident A1) out of eight sampled residents. Findings include: A review of Resident A1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pain and osteoarthritis (is inflammation of one or more joints and is the most common form of arthritis that affects joints in the hand, spine, knees, and hips). A review of the resident's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) assessment dated [DATE], indicated that Resident A1's completed Brief Interview for Mental Status [(BIMS) a tool that assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information] score was 15 out of 15 (a score of 13 to 15 suggests intact cognition) and cognitively intact. Additionally, the MDS indicated that the Resident was able to independently ambulate with the use of a walker. A review of an investigation to an incident that occurred on August 31, 2024, at 8:30 PM, completed by Employee 1 (Registered Nurse [RN]), revealed that she was called to a Resident's room by a nurse who reported injury to ankle from slippage. Resident ambulated independently with her rolling walker to bedside drawer. While walking, she slipped on a wet floor caused by leaking window in her room. Resident denied falling and stated she was able to hold onto handle of her walker; however, she reported twisting her ankle during the event. RN assessment completed; right ankle noted to be tender to touch with mild edema. No visible bruises or deformity observed at the time of assessment. Resident pain rated 6/10 stated I was going over there to get my clothes and slipped on the water and hurt my leg. Ice applied to affected limb, medicated with acetaminophen 625 mg PO (by mouth), wet sign placed in room, and Resident encouraged to remain in bed and call for assistance. Bath blankets placed on windowsill and by the window to absorb water, work order submitted to maintenance department. MD contacted and ankle X-ray requested. Resident is her own responsible party, emergency contact notified, and a nursing communication sent to therapy. Further review of Resident A1's clinical record revealed negative x-ray results of her right ankle; however, moderate right ankle pain persisted with movement, touch, and weight bearing. Physician aware new orders for rest, ice, elevation/positioning. An interview with Resident A1 on October 9, 2024, at 10:49 AM, revealed that she reported that the window inside of her old room leaked when it rained heavy and was windy outside and would trickle onto her windowsill, the heating/cooling unit, and pool on her floor. Resident A1 stated that she reported this to her social worker prior to slipping on August 31, 2024, and was told that a maintenance repair ticket was entered and would be completed. Additionally, Resident A1 reported that the facility did not attempt to repair the leaky window in her room until after she slipped on the water. A review of work order number 1922 that was created by Employee 2 (Therapy Department) on August 7, 2024, at 9:13 AM, indicated that Resident A1 reported a leaking window in room/area 303. Further review of work order number 1922 that was updated on August 12, 2024, at 7:34 AM, by Employee 3 (Maintenance worker) commended that windows need to be replaced and set the order to completed. Additionally, a review of work order number 1947 created on August 31, 2024, at 8:50 PM, by Employee 1, after Resident A1's slip, revealed please repair the leaking window 303B bedroom window. Further review of work order number 1947 that was updated on September 4, 2024, at 3:08 PM, by Employee 3, commended that Resident A1 was moved and was completed. During an interview with the facility's Regional Maintenance Director or October 9, 2024, at 11:48 AM, revealed that the facility obtained a quote to repair the leaking windows on September 19, 2024, and that the facility was planning to have them repaired with upcoming facility renovations. The facility failed to timely respond and implement effective safety measures to deter Resident A1's accident with minor injury, right ankle sprain. An interview with the facility's Nursing Home Administrator on October 9, 2024, at 1:00 PM, confirmed that the facility failed to timely respond to Resident A1's concerns related to the leaking window in her room, which resulted in the Resident slipping on a wet floor and spraining her right ankle. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on a review of resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to ensure that the facility considered the views and recommendations raised during resident group meetings, including experiences expressed by five residents out of five during a resident group interview (Residents 18, 31, 36, 49, and 86), and failed to ensure that the facility acted upon grievances and concerns raised during resident group meetings for one resident out of the 21 sampled (Resident 22). Findings include: The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. A review of Resident Council meeting minutes dated June 25, 2024, revealed that residents in attendance raised concerns regarding vegetarian food options such as vegetarian hotdogs and vegetarian bacon. A review of the facility's June 2024 grievance log revealed no documentation of the concerns residents raised regarding the resident council meeting on June 25, 2024. A review of Resident Council meeting minutes dated July 23, 2024, revealed no documented evidence of a response to residents' concerns regarding vegetarian food options. During an interview on August 7, 2024, at 9:50 AM, Resident 22, indicated she raised concerns during a resident council meeting on June 25, 2024, that were not addressed or resolved. She indicated that she received no response from the facility individually or at following resident council or food committee meetings. During an interview on August 8, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) was unable to provide documentation that the concerns Resident 22 raised during the resident group meeting regarding her diet preferences were addressed or resolved. A review of Resident Council meeting minutes dated May 23, 2024, revealed the Treasurer's Report section. The area for the amount was blank. The meeting minutes had no documented evidence of resident fund monetary activities or related discussions. A review of Resident Council meeting minutes dated June 25, 2024, revealed the Treasurer's Report section. The area for the amount indicated a value of $1186.56. The meeting minutes had no documented evidence of resident fund monetary activities or related discussions. A review of Resident Council meeting minutes dated July 23, 2024, revealed the Treasurer's Report section. The area for amount indicated a value of $1186.56. The meeting minutes had no documented evidence of resident fund monetary activities or related discussions. During a resident group interview on August 8, 2024, residents in attendance (Residents 18, 31, 36, 49, and 86) were not able to explain why there was a treasurer's report on the monthly resident council meeting minutes. Residents in attendance were unable to recall discussing the resident fund or any decision making regarding the resident fund. The residents indicated that they do not recall staff asking for resident input or considering their views for resident fund activities. During an interview on August 8, 2024, at 1:15 PM, Employee 1, Activities Director, demonstrated financial records she keeps regarding resident fund monetary activities. Employee 1 explained that funds are raised by snack cart purchases made by residents and employees. She also indicated that funds are raised through employee donations. Employee 1 was not able to provide documented evidence of resident involvement, input or recommendations regarding resident fund monetary activities. During an interview on August 8, 2024, at approximately 1:30 PM, the Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to consider the view of residents during resident group meetings. The NHA was not able to provide documented evidence that residents views and input were discussed regarding resident fund activities. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement a person-centered care plan to meet each resident's needs for four of 21 sampled residents (Residents 7, 8, 64, and 66). Findings including: Review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include heart failure (chronic condition in which the heart does not pump blood as well as it should), and the presence of a pacemaker (small battery-powered device that prevents the heart from beating too slowly, surgically placed under the skin near the collar bone). A review of the resident's current comprehensive care plan, conducted during the survey ending August 9, 2024, failed to include the presence of a pacemaker. The care plan did not include how the facility would monitor the pacemaker or evaluate the resident for symptoms related to the pacemaker not properly functioning. Interview with the director of nursing on August 8, 2024, at 1:00 PM confirmed that the facility failed to address the care and management of Resident 8's pacemaker on the resident's person-centered plan of care. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function). A care plan indicated Resident 7 is at risk for falls related to generalized weakness, poor balance, unsteady gait, and fall from home was initiated on November 15, 2023. Interventions in place to mitigate Resident 7's risk for falling included ensuring her bed is in the lowest position. During an observation and interview on August 6, 2024, at 11:10 AM, in resident room [ROOM NUMBER], Employee 2, Licensed Practical Nurse (LPN), confirmed Resident 7 was in bed and her bed was not in the lowest position. Following inquiries made during the interview, Employee 2, LPN, lowered Resident 7's bed to the lowest position. A clinical record review revealed that Resident 66 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood). A care plan indicated Resident 66 is at risk for falls related to impaired mobility and a history of falls in the facility initiated on July 29, 2024. Interventions in place to mitigate Resident 66's risk of falling included ensuring his call bell is within reach. A facility fall risk evaluation dated July 29, 2024, revealed Resident 66 is at high risk of falling. During an observation and interview on August 6, 2024, at 11:40 AM, in resident room [ROOM NUMBER], Employee 3, Nurse Aide (NA), confirmed Resident 66 was in bed and that his call bell was not within reach. Following inquiries made during the interview, Employee 3, NA, picked Resident 66's call bell from the floor and positioned it within reach of the resident. A clinical record review revealed that Resident 64 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down). A care plan indicated Resident 64 is at risk for falls related to general weakness and a history of noted falls initiated on December 13, 2023. Interventions in place to mitigate Resident 64's risk of falls include a bed clip alarm (a device that will ring to notify staff the resident is attempting to ambulate from bed) and for Resident 64's bed to be in the lowest position. A facility fall risk evaluation dated June 2, 2024 revealed Resident 64 is a high risk for falling. During an observation and interview on August 6, 2024, at 12:20 PM, in resident room [ROOM NUMBER], Employee 4, LPN, confirmed that Resident 64 was in bed and her bed alarm was not connected. Employee 4, LPN, also confirmed that Resident 64's bed was not in the lowest position. Following inquiries made during the interview, Employee 4, LPN, connected Resident 64's bed alarm and lowered the bed to the lowest position. During an interview on August 9, 2024, at approximately 9:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that person-centered care plans are implemented to mitigate residents' risk of falling. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on a review of clinical records, facility provided documents, facility's planned cycle menu, and resident and staff interviews it was determined that the facility failed to ensure a pre-planned nutritionally adequate menu for one resident out of 21 residents sampled (Resident 22). Findings include: Review of Resident 22's clinical record revealed admission to the facility on [DATE], with diagnoses to have included gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), and cerebral atherosclerosis (a build-up of plaques in the blood vessels of the brain). A review of an April 29, 2024, admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care), revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 14. A review of facility document entitled Nutritional Risk Assessment/Full - V4 dated April 30, 2024, indicating resident 22 has distinct food preferences, and is a vegetarian but eats fish and seafood. No recommendations at this time, nutrition plan of care (POC) established. A review of facility document entitled Resident Profile indicating the resident is on a regular diet, no meat products, fish ok. Dislikes/intolerances meat, pears, grilled cheese. (Having no mention of her being a vegetarian, and or what her distinct food preferences are). The resident's plan of care (POC) initiated on April 30, 2024, identified that Resident 22 is at risk for altered nutritional status related to therapeutic diet, diuretic therapy, and diagnosis of COPD, hypertension, GERD, heart failure, and depression, date initiated April 30, 2024, with a noted goal that the resident will not have a significant weight change (gain or loss) through the next review with a target date of September 20, 2024. Interventions planned were to provide meals, snacks, fluids based on resident food preferences and physician orders, review the importance of maintaining the ordered therapeutic diet. Encourage compliance and discuss risks related to not following diet as ordered; honor residents' preferences when choice is made, and periodically obtain resident's weight, evaluate, and report to registered dietician (RD), physician, and family of significant weight changes, date-initiated April 30, 2024. (Having no mention of her being a vegetarian, and or what her distinct food preferences are). A review of facility document entitled Resident Council Meeting Minutes dated June 25, 2024, revealing resident 22 had attended, and had voiced concerns, questions regarding food choices, and would like veggie hot dogs, and veggie bacon as stated during an interview with Employee 1, Activity Director, on August 7, 2024, at approximately 2:00 PM. A review of a document entitled June 25, 2024, Food committee resolutions indicating Resident 22 had voiced concerns, questions regarding food choices, and that the facility explained several Pescatarian (primarily a vegetarian diet that includes fish and other seafood) options were available. A review of the resident' meal ticket dated June 26, 2024, revealed that Resident 22 was on a regular diet, no meat products, fish ok. Dislikes/intolerances meat, pears, grilled cheese. (Having no mention of her being a vegetarian diet - preference). A review of Resident Council Meeting Minutes dated July 23, 2024, made no indication of any follow up, or resolution (old business) regarding resident 22's concern and request for veggie hot dogs, and veggie bacon as stated in the June 25, 2024 Resident Council Meeting Minutes, as confirmed during an interview with Employee 1, Activity Director, on August 7, 2024, at approximately 2:00 PM. During an interview with alert, and oriented Resident 22 on August 7, 2024, at approximately 9:50 AM, revealed she is a vegetarian who also eats tuna and seafood. She stated that staff had not spoken with her regarding her weight loss, and or vegetarian preferences, selections, and or satisfaction. She further stated that staff is well aware of her vegetarian preference and has even voiced concerns, dissatisfaction, with no response from the facility. A review of the facility diet manual reviewed May 1, 2024, revealed that the diet manual did include a vegetarian diet. However, there was no planned menu at the time surveyed of a planned vegetarian diet, as confirmed during an interview with the RD on August 7, 2024, at approximately 2:40 PM. During an interview with the Nursing Home Administrator (NHA) on August 8, 2024, at approximately 10:40 AM, confirmed that the facility failed to plan, in advance, a nutritionally complete vegetarian diet to meet Resident 22's nutritional needs and preferences. The NHA also confirmed the resident had a significant weight loss in 8 days (May 23, to May 31, 2024). Refer F692 28 Pa. Code 211.6 (a) Dietary services. 28 Pa. Code 201.18 (e)(2)(3) Management

Based on observation, review of clinical records, select facility policy, and resident and staff interviews it was determined that the facility failed to timely identify and assess a resident's weight loss, implement individualized nutritional support measures to maintain or improve nutritional parameters, and to timely consult with the physician and notify the resident of a significant weight loss for one resident (Resident 22) and failed to implement a planned nutrition intervention in response to weight loss for one resident (Resident 142) of seven sampled residents. Findings include: A review of facility policy entitled Weight Management Guideline, last reviewed by the facility on May 1, 2024, is the identification of weight loss (planned, or unplanned) to determine accurate weight with supporting documentation to prevent, monitor, or intervene with undesirable weight. Weight variances include weight change of 5 Ibs or weight change of 3 Ibs if weight less than 100 Ibs. If variance is noted, staff will determine if resident has a change such as a splint, edema, prosthesis, new shoes, bag etc. Significant weight variance is defined as: 5 % in one month (30 days) 7.5% in three months (90 days) 10% in six months (180 days) Review of Resident 22's clinical record revealed admission to the facility on [DATE], with diagnoses to have included gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), and cerebral atherosclerosis (a build-up of plaques in the blood vessels of the brain). A review of an April 29, 2024, admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care), revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 14. Section K 0200 Height and Weight, 152 pounds. Resident 22's clinical record reflected a primary representative (responsible party) as the resident herself. The resident's care plan initiated on April 30, 2024, identified that Resident 22 is at risk for altered nutritional status related to therapeutic diet, diuretic therapy, and diagnosis of COPD, hypertension, GERD, heart failure, and depression, date initiated April 30, 2024, with a noted goal that the resident will not have a significant weight change (gain or loss) through the next review with a target date of September 20, 2024. Interventions planned were to provide meals, snacks, fluids based on resident food preferences and physician orders, review the importance of maintaining the ordered therapeutic diet. Encourage compliance and discuss risks related to not following diet as ordered; honor residents' preferences when choice is made, and periodically obtain resident's weight, evaluate, and report to registered dietician (RD), physician, and family of significant weight changes, date-initiated April 30, 2024. A review of a document entitled admission Nutritional Assessment (Mini) MNA dated April 30, 2024, indicated the resident was at risk for malnutrition with a score of 11.0 (a score of 8-11 indicates at risk of malnutrition). A review of the resident's weight record revealed the resident's height as 66.0 inches and that her ideal body weight (IBW) range is between 149.0 - 180.0, with the following recorded weights: April 24, 2024 (12:07 PM) - 151.8 lbs (Admission) May 9, 2024 (2:22 PM) - 151.0 lbs May 14, 2024 (2:58 PM) - 153.6 lbs May 21, 2024 (11:23 AM) - 158.0 lbs May 23, 2024 (2:08 PM) - 158.1 lbs May 31, 2024 (10:30 AM) - 148.0 lbs weight loss (6.39 %) in 8 days June 1, 2024 (10:41 AM) - 148.0 lbs June 4, 2024 (1:30 PM) - 149.0 lbs Resident 22 lost a total of 10.1 lbs. or 6.39 % of body weight in 8 days (May 23, to May 31, 2024). During an interview with alert, and oriented Resident 22 on August 7, 2024, at approximately 9:50 AM, revealed she is a vegetarian who also eats tuna and seafood. In further questioning, the resident indicated being aware of the unplanned weight loss by the way she feels. She stated that staff had not spoken with her regarding her weight loss, and or vegetarian preferences, selections, and or satisfaction. She further stated that staff is well aware of her vegetarian preference and has even voiced concerns, dissatisfaction, with no response from the facility. At the time of the survey ending August 9, 2024, there were no documented evidence that the facility had identified the significant, unplanned weight loss. Nor that a nutritional assessment was conducted and or documentation from the RD regarding the resident's weight loss noted on May 31, 2024. There was no documented evidence that the resident or physician was notified of the weight loss. The resident's weight dropped below the goal range of 149.0 - 180.0 lbs (148.0 Ibs. on May 31, and June 1, 2024), but there was no evidence of reassessment by the RD or revision of the resident's care plan or that the RD evaluated the resident's significant weight for additional interventions necessary to deter further weight loss. There was no evidence at the time of the survey ending August 9, 2024, that the facility had timely acted upon the resident's weight loss and developed and implemented nutritional support measures to maintain acceptable nutritional parameters and deter progressive weight loss. Interview with the Director of Nursing on August 8, 2024, at approximately 9:20 AM, confirmed that the facility failed to timely identify, address, and implement weight loss interventions, and timely notify the resident, and or consult with the physician to improve Resident 22's nutritional status. Review of the clinical record revealed that Resident 142 was admitted to the facility on [DATE], with diagnoses which include subarachnoid hemorrhage (sudden rupture of an aneurysm in an artery in the brain), diabetes, and dysphagia (difficulty swallowing). A review of the resident's weight record revealed the following recorded weights: July 27, 2024 115.6 pounds July 29, 2024 108.6 pounds August 1, 2024 104.6 pounds August 5, 2024 100.4 pounds (reflective of a 13.1% significant weight loss since July 27, 2024) A mini nutritional assessment dated [DATE], indicated the resident weighed 104.6 pounds, had a moderate decrease in food intake, and was malnourished (imbalance between the nutrients your body needs to function and the nutrients it gets). A physician order dated August 7, 2024, noted an order for a Healthshake (nutritional beverage) 4 ounces with meals for weight loss. Observation during the lunch meal on August 9, 2024, at 12:00 PM revealed that the Healthshake was not provided with the resident's lunch as ordered by the physician. Review of the resident's meal ticket failed to indicate that the resident was to receive a Healthshake. Interview with the registered dietitian (RD) on August 9, 2024, at approximately 12:20 PM confirmed that Resident 142 had a significant weight loss and that a 4 ounce Healthshake with meals was ordered by the physician. The RD confirmed that the order for the 4 ounce Healthshake was not added to the resident's meal ticket. Refer 803 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure comprehensive care plans were developed and revised with participation of the resident and the resident's representative for three residents out of 21 sampled (Residents 15, 31, and 49). Findings include: A clinical record review revealed Resident 15 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and cerebral infarction (brain damage that results from a lack of blood). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 6, 2024, revealed that Resident 15 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). During an interview on August 6, 2024, at 11:00 AM, Resident 15 indicated that she has not participated in any recent care plan meetings. She was not able to recall being invited to participate in the development or revision of her care plan. Resident 15 explained that she would be interested in attending because she would like to discuss her discharge options and goals. A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and chronic respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 31 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact). During an interview on August 6, 2024, at 11:25 AM, Resident 31 indicated that she has not participated in any recent care plan meetings. She was not able to recall being invited to participate in the development or revision of her care plan. Resident 31 indicated that she would participate in care plan meetings and participate in the revision or development of her plan of care if invited by the facility. A clinical record review revealed Resident 49 was admitted to the facility on [DATE], with diagnoses that include atherosclerotic heart disease (a condition that involves the buildup of plaque on artery walls). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 49 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). During an interview on August 6, 2024, at 12:00 PM, Resident 49 indicated that he is not included in his care plan meetings or the development or revision of his care plan. He indicated that he would like to attend these meetings but explained that the facility has not invited him to attend. During an interview on August 9, 2024, at approximately 9:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents are provided an opportunity to participate in development and revisions of their comprehensive care plans. The NHA and DON confirmed that the interdisciplinary team meets quarterly to discuss, revise, and develop each resident's plan of care. The DON and NHA were unable to provide documented evidence that Residents 15, 31, and 49 were offered the opportunity to participate in their care plan meetings over the past 6 months. The DON and NHA confirmed that the facility must include residents in the development and revision of their care plans to the greatest extent possible. 28 Pa. Code 201.29(a) Resident Rights 28 Pa Code 211.12 (d)(3) Nursing services.

Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that one resident out of 18 sampled (Resident 39) was free from physical abuse, perpetrated by another resident (Resident CR4). Findings include: A review of facility policy titled Abuse of Residents, last reviewed by the facility on May 1, 2024, revealed it is the facility policy that acts of physical abuse directed against residents are absolutely prohibited. The policy indicates that each resident has the right to be free from physical abuse and shall not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, family members, friends, or other individuals. The policy defines physical abuse as including but not limited to hitting, slapping, punching, or kicking. A clinical record review revealed Resident 39 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 13, 2024, revealed that Resident 39 is severely cognitively impaired with a BIMS score of 2 (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 01-07 indicates severe cognitive impairment). A clinical record review revealed that Resident CR4, was admitted to the facility on [DATE], with diagnoses that include 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) and dementia. A review of an annual MDS assessment dated [DATE], revealed that Resident CR4 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognitively intact). A care plan review revealed Resident CR4 has behaviors related to dementia with agitation, makes accusatory statements, and is physically and verbally aggressive toward others initiated on April 14, 2024. Interventions implemented to assist Resident CR4 with these behaviors include approaching the resident in a calm manner to avoid frustration and behavior escalation, giving the resident non-judgmental support, and keeping the resident safe during episodes of behaviors. A progress note dated April 14, 2024, at 6:09 AM indicated that Resident CR4 propelled himself up the hallway in his wheelchair cursing, yelling, and name-calling at staff. The resident became agitated and started throwing a snack tray and chair at staff. Resident CR4 attempted to kick staff. A progress note dated April 15, 2024, at 6:46 AM indicated that Resident CR4 was yelling and cursing at staff. A progress note dated April 15, 2024, at 7:00 AM indicated that Resident CR4 displayed verbally aggressive behavior with staff at midnight the previous shift. The note indicated he was cursing and yelling at staff. A progress note dated April 16, 2024, at 6:32 AM indicated that Resident CR4 was yelling and cursing at staff at the beginning of the shift, but displayed no additional behaviors. A facility incident report dated April 19, 2024, at 12:05 PM indicated that Resident CR4 was observed yelling at Resident 39. Staff attempted to redirect Resident CR4, explaining that Resident 39 did not understand him; however, the redirection was not effective, and Resident CR4 continued yelling. A witness statement dated April 19, 2024, revealed that Employee 3, Nurse Aide (NA), was assisting residents in the dining room, on April 19, 2024, at 12:05 PM when she witnessed Resident CR4 punch and kick Resident 39. Employee 3, NA, indicated that she immediately removed Resident 39 for safety and notified the nurse. A witness statement dated April 19, 2024, revealed that Employee 5, NA, heard his coworker scream for help on April 19, 2024, at 12:05 PM. When he arrived, he witnessed Resident CR4 attempting to throw coffee on Resident 39. Employee 5, NA, indicated that Resident CR4 has been having outbursts and has been verbally abusive to the same resident weeks prior. A progress note dated April 19, 2024, at 12:05 PM indicated that Resident CR4 was screaming and yelling at staff. Staff witnessed Resident CR4 punch Resident 39 in the face and throw a full glass of orange juice at him. The note indicated that Resident CR4 stated, He doesn't belong here. I will beat the living sh** out of him! Resident CR4 refused care and was swinging his fist at staff. The note indicated that Resident CR4 was sent to the community hospital due to combative and aggressive behavior. A progress note dated April 19, 2024, at 12:07 PM indicated that Resident 39 is alert only to himself, does not seem to understand questions, and is not able to verbalize what occured {in the dining room on on April 19, 2024, at 12:05 PM}. The note indicated that prior to lunch being served, Resident 39 picked up an orange juice that was sitting on a table and started to drink it. Resident CR4 was sitting in the dining room and started yelling at Resident 39, saying, That's my orange juice! Resident CR4 approached Resident 39, picked up another glass of orange juice, and threw it on Resident 39, covering his shirt and lap in juice. Resident 39 did not appear to understand and continued to hold the glass of orange juice. Resident CR4 then punched Resident 39 in the face. Resident 39 was removed from the area for safety. A progress note dated April 19, 2024, at 2:34 PM indicated Resident 39 had no complaints of pain. A progress note dated April 20, 2024, at 5:56 PM indicated that Resident 39 denies any pain or discomfort and neurological checks were within normal limits. The note indicated Resident 39 had no redness, swelling, or erythema noted. During an interview on August 9, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident CR4 threw orange juice on Resident 39 and punched him in the face. The NHA and DON confirmed that the facility failed to prevent Resident 39 from abuse perpetrated by Resident CR4. The NHA confirmed that it is the facility's responsibility to ensure residents are not subjected to abuse by anyone, including other residents. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of clinical records and select facility policy, observation and staff and resident interview, it was determined that the facility failed to timely identify and treat declines in skin integrity to prevent pressure sore development for one resident (Resident 40) out of 18 residents sampled. Findings include: A review of the facility policy for Skin Integrity Management reviewed by the facility February 2014 revealed Residents identified as a risk for the development of pressure ulcers will have a plan and intervention included in the care plan to address risk factors for development of pressure ulcers, initiate the pressure ulcer investigation form. The wound treatment protocol will be reviewed to determine the appropriate treatment. The responsible party will be notified. A review of the clinical record revealed that Resident 40, a severely, cognitively impaired resident, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An quarterly Minimum Data Set assessment ( MDS process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated June 19, 2014, revealed that the resident required maximum assistance with his ADLs (Activities of Daily Living), was at risk for developing pressure areas and could not move independently in the bed. A review of admission monthly recap physician's orders and plan of care dated June 2014 revealed an order for [REDACTED]. Review of a Pressure Ulcer Evaluation form dated June 20, 2014, revealed a unstageable, pressure area on his left ankle measuring 1.5 cm x 2.5 cm, black Eschar (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) or Eschar (tan, brown or black, thick leathery dead skin) in the wound bed). A review of a certified Registered Nurse Practioner (CRNP) note dated June 20, 2014, at 9:24 AM revealed multiple pressure ulcers and a new pressure area on the residents left lateral (outer) ankle measuring 1.5 cm x 2.5 cm. The area was noted to be covered with black, dry eschar. The CRNP noted that the resident had multiple pressure ulcers at multiple sites and the plan was to continue Santyl. However, there was no documented evidence of the treatment ordered for the newly identified unstageable pressure area found on the resident's ankle on June 20, 2014, as the order noted to apply Santyl to the left hip, right & left buttocks and sacral wound daily. A physician's order dated July 28, 2014, was noted to cleanse with saline, pat dry apply Santyl to left outer ankle, cover with dry dressing. On September 9, 2014, this treatment was changed to Acetic acid solution 5 %, apply to ankle twice a day. The treatment administration record indicated that nursing staff did not provide this treatment to the resident from September 9, 2014, through September 11, 2014. There was no documented evidence that the resident's responsible party was notified of the pressure sore on the resident's ankle. An observation of the resident's left outer ankle pressure area on September 17, 2014 at 2 PM revealed 2.5 cm x 2.5 cm x <0.1 cm round area, beefy red with white slough surrounding and pink granulation tissue surrounding the area. There was a very small area of black eschar on the top and the bottom of the area. A review of a the facility's investigation into the pressure sore development dated August 10, 2014, and a pressure ulcer evaluation dated August 11, 2014 revealed that the resident had a stage 1 non-blanchable reddened pressure area on his right outer ankle area measuring 3 cm x 2.5 cm. The facility's investigation noted that this resident wore boots. There was no documentation of any off loading devices prior to the discovery of this pressure area. New facility interventions for pressure sore prevention to this pressure area included padding the area and to off load feet on pillows. During an interview September 16, 2014 the third floor RN unit manager stated that resident had foot drop and did not wear boots. She further stated that prior to the discovery of the pressure sore on the resident's right ankle on August 10, 2014, his feet were not off loaded, in or out of bed. During an interview on September 17, 2014 at 2 PM the Director of Nursing confirmed that staff applied Santyl to the left ankle area without a physician's order and that there was no documented evidence that nursing consistently provided treatment to the left ankle. The DON also confirmed that the resident's responsible party was not notified of the pressure sore on the resident's left ankle according to facility policy During an interview September 17 , 2014 at 1:30PM, the Director of Nursing was unable to provide evidence of the consistent application of preventative measures to deter pressure development. 28 Pa Code 211.12 (a)(d)(1)(3)(5) Nursing services previously cited 7/31/14, 5/16/2014, 10/3/2013 28 Pa. Code 211.10(a)(c)(d) Resident care policies

Based on a review of clinical records, select facility policy and resident incident reports, observations and staff interviews it was determined that the facility to timely address fall risk factors and develop and implement safety measures to prevent accidents and injury for one resident out of 18 sampled (Resident 12). Findings include: Review of the facility's policy entitled "Fall Risk Assessment" reviewed by the facility February 2014 revealed that the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident and/or the family about a history of the resident falling. The nursing staff, Attending Physician and Consultant Pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such those have side affects of dizziness, ataxia or hypotension. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff, with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the Resident 12's clinical record revealed admission to the facility on [DATE], with a history of falls which occurred prior to admission to the facility. According to a fall risk assessment dated [DATE], the resident had a history of [REDACTED]. Review of nursing documentation dated September 6, 2014 at 3:20 AM, revealed that the resident was found on the floor in front of her bed. The resident stated she lost her balance going to the bathroom and was not using her walker. She hit her face on the bottom of the bed, which resulted in four skin tears to the right arm, one skin tear to the right knee and from the bridge of the nose down a 2 cm x 2 cm laceration and nose bleeding. She was transferred to the hospital to be evaluated and returned on September 6, 2014, with sutures in the nose and a [DIAGNOSES REDACTED]. A corresponding resident incident report dated September 6, 2014, also indicated that the resident was found sitting on the floor in front of her bed with a 2 x 2 cm laceration to the bridge of nose. Her nose was bleeding from inside and she had four (4) skin tears on the right arm and one skin tear on the right knee. She was returned to bed and at that time complained of right sided pain. The resident stated she had been going to the bathroom at the time of the fall. She was alert and oriented to person, situation and place according to the report. The predisposing environmental factors contributing to this fall were identified as poor lighting, non-skid socks not in place and improper footwear. The resident was last seen at 2:20 AM and was offered assistance to the bathroom at that time per the incident report. An admission Minimum Data Set Assessment (MDS) dated [DATE], revealed that the resident required two person assistance for bed mobility, transfers and toilet use and was not steady for balance during transitions and walking. The resident was observed throughout the days of the survey on September 15, 16, 17, 18, 2014, with periorbital ecchymosis and skin tears to her body related to this fall, which the resident reported occurred while trying to get to the bathroom. She was also observed to be short of breath. This resident was identified as having a history of falls prior to admission and was considered at moderate risk for falls on August 29, 2014, based on the risk factors in her fall risk assessment. On September 6, 2014, after she incurred a nasal fracture, the facility developed a plan of care addressing the problem/need of falls. The facility failed to develop and implement an initial care plan to sufficiently address the resident's risk for falls from the time of the resident's admission. This plan of care (September 6, 2014) indicated that the resident had a fall with injuries (nasal fracture) and interventions including an alarm to the resident's bed and to encourage the resident and assist her to wear appropriate non-slip footwear were now planned. The Director of Nursing confirmed on September 18, 2014, timely addressed any modifiable fall risk factors to prevent a fall with an injury for this resident and had identified the environmental factors that may contribute to falling, such as lighting and foot wear. The resident was identified at moderate risk for falls on August 29, 2014, but the facility failed to develop and implement adequate fall prevention and safety approaches until after the resident's fall with injury on September 6, 2014. 28 Pa Code: 211.10 (a)(d) Resident care policies. Previously cited 5/16/14. 28 Pa Code: 211.12 (a)(c)(d)(3)(5)Nursing services. Previously cited 10/3/13, 5/16/14, 7/31/14.

Based on clinical record review, an Event Report submitted to the State Survey Agency, and select Incident/Accident Investigations, observation and staff interview, it was determined that the facility failed to consistently implement safety interventions, including adequate staff supervision, to deter accidents and elopement for three of 14 residents (Residents 31, 102 and 109). Findings include: Clinical record review revealed that Resident 31 had [DIAGNOSES REDACTED]. Review of the April 30, 2011, physician orders [REDACTED]. Observation of Resident 31 from 10:45 a.m., thru 1:30 p.m., revealed that the resident was in various locations of the facility unsupervised with no audible alarm in place. Interview with Employee 2, LPN, on May 5, 2011, at 1:30 p.m., confirmed that the audible alarm on the chair was not in place as ordered by the physician to prevent falls/accidents. Clinical record review revealed that Resident 109 had diagnoses, which included Parkinson disease and cerebrovascular accident with right hemiparesis. Review of the resident's care plan to address falls dated March 14, 2011, indicated that the resident was at risk for falls. Planned interventions to prevent falls included a chair alarm. Review of a nurses note dated, April 26, 2011, at 8:00 a.m., revealed that the resident had a fall, which was witnessed by another resident in the dining room. It was noted that an alarm was sounding prior to entering dining room area. Review of a resident Incident/Accident Report dated, April 26, 2011, revealed that the cause of the fall was no staff supervision in the dining room. It was noted that staff were alerted to the fall by another resident who approached staff to report the fall. There was no mention as to the effectiveness of the alarm as an intervention to prevent the resident's fall. The intervention implemented to prevent recurrence was to have the resident supervised when in the dining room. Observation on May 4, 2011, at 9:30 a.m., revealed that three residents (Residents 94, 106 and 109) were present in the dining room without staff supervision. All three of these residents had alarming devices attached to their wheelchairs due to being at high risk for falls. Interview with the administrator on May 4, 2011, at 2:00 p.m., confirmed that the aforementioned residents were fall risks and should not have been left in the dining room without staff supervision. Clinical record review revealed that Resident 102 was admitted to the facility on [DATE], and has multiple [DIAGNOSES REDACTED]. According to a review of his current comprehensive plan of care, which was initiated on March 31, 2011, revealed that the resident is at risk for elopement due to presenting with cognitive impairment and being independently mobile. Planned interventions included, but were not limited to, using an audible alarm system to alert staff to exit seeking behavior, to monitor the resident for "tailgating" when visitors are in facility, to use an electronic bracelet on left ankle and routine monitoring. The resident utilizes a Wanderguard (alarmed bracelet-like device, which is utilized to notify staff of attempts at an unsupervised exit from the facility). He also resides on the Fourth Floor Nursing unit, which is a locked unit that requires a code to open the two exit doors. Review of nursing documentation on April 1, 2011 (no time specified) revealed the resident was out of bed and ambulating ad lib in the hall, pacing in the hall attempting to open doors. On April 2, 2011 at 11:00 AM, it was noted that the resident was looking to go home or looking to leave the facility. On April 3, 2011, on the 3 PM to 11 PM shift, it was noted that the resident continued to be exit seeking , ambulating through the halls, wandering in other residents rooms. He was difficult to redirect and confused. On April 26, 2011 at 12:40 PM, it was noted that the Administrator alerted staff that the resident was outside on the sidewalk. It was noted that the alarm sounded and staff were alerted to check the exit. The resident's Wanderguard bracelet was intact on the left ankle. It was also noted that he wanders with poor safety awareness. On April 27, 2011 at 8:00 AM, it was also noted that he attempted to open the exit doors. According to an Event Report submitted to the State Survey Agency on April 26, 2011, it was noted that at 12:40 PM on that date the following was noted: the door alarm to the first floor stairwell was sounding. The Maintenance Director and the Director of Nursing responded immediately and found the resident outside on the side walk in front of the facility. He was escorted back to the Fourth floor. The resident is alert with periods of confusion and could follow conversation. His Wanderguard was intact to his left ankle, was tested and found to be functional. When asked as to what happened, he said "It was a long way down." He stated that a man pushed the code and the door opened. The door wasn't locked and he went through. He went outside and walked on "Bareplanks" (sidewalk). Review of a a corresponding Incident/Accident Investigative Report, which was initiated on April 26, 2011, revealed that on April 27, 2011, each door leading from the hallway into the stair tower was tested for the amount of time it took to close each door. It was noted that the 4th Floor exit door (on the West side) took 8 seconds to close, whereby, the exit door at the other end of the hallway took only 5 seconds to close. The exit doors on the 1st, 2nd and 3rd Floor took between 4 seconds-6 seconds to close, but the average closing time was noted to be about 5 seconds. In response to this incident, the West side door was altered to close at 5 seconds. During the course of this investigation, Resident 102 gave a description of the man that he said pushed the code and opened the door that the resident used to leave the facility as "tall, thin man with dark hair." A written statement obtained from the Maintenance Director revealed that on April 26, 2011 around 12:30 PM, he was walking West down the 1st floor hallway when he saw a man in blue scrubs (tall, thin) coming from the West stair tower. The Maintenance Director then heard the stair tower exit alarm go off. The Maintenance Director went to the alarm station and saw that it was the 1st floor West exit alarming. He ran outside and found Resident 102 on the sidewalk in front of the building. During an observation on May 4, 2011 at approximately 2:05 PM of how the resident may have successfully exited the facility, it was revealed by the Director of Nursing during this observation, that the resident went from the 4th floor West hall exit door (which is alarmed and utilizes a code), walked down the stairs through the 1st floor stair tower and exited the 1st floor stair tower to the outside. He was found on the sidewalk, approximately 9 feet from the facility (this area is right next to a highly traveled main road). Review of inservices conducted with staff on April 27, 2011 and April 28, 2011 in response to this incident, indicated that door codes are not to be shared with residents or visitors, to take extra care to ensure no residents follow you through the stair well doors, take extra care to ensure no residents are around as you punch in the code and open the door and once through the door, make sure that the door closes tight behind you and that a resident is not following you. The facility failed to demonstrate that the resident was consistently provided with adequate supervision and consistent implementation of care planned approaches (monitor the resident for tailgaiting) to prevent unsupervised exit from the facility. 483.25(h) Free of Accident Hazards/Supervision/Devices. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 2/12/10, 11/3/10 28 Pa. Code 201.18(e)(1) Management. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 2/12/10 28 Pa. Code 211.10(d) Resident care policies. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 2/12/10, 4/21/10 28 Pa. Code 211.12(a) Nursing services. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 4/22/09, 2/12/10, 4/21/10, 11/3/10 28 Pa. Code 211.12(c)(d)(5) Nursing services. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 4/22/09, 4/27/09, 2/12/10, 4/21/10, 11/3/10 28 Pa. Code 211.12(d)(1) Nursing services. Continuing deficiency from 3/4/11 Previously cited 3/12/09, 4/22/09, 2/12/10

Based on review of select facility policies and procedures, clinical records, and Event Reports, observation and staff interview, it was determined that the facility failed to provide sufficient staff assistance/supervision and effectively implement planned safety interventions to prevent accidents for two of 21 sampled residents (Residents 62 and 86) and failed to maintain an environment free of potential accident hazards on one of four nursing units (fourth floor). Findings include: Review of facility policy entitled, "Fall and Injury Management," last reviewed on December 20, 2010, indicated that the facility strived to reduce the risk for falls and injuries. "The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risks of falls or injuries while maximizing dignity and independence." Clinical record review revealed that Resident 62 had [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired, was totally dependent on others for activities of daily living and was totally dependent on two persons for bed mobility. The facility's Data Collection form, dated April 6, 2010, revealed that the resident was considered to be a fall risk. Review of the facility's Event Data Collection Worksheet, dated May 17, 2010, at 4:10 PM, revealed that the resident was in bed receiving care by a nurse aide, (Employee 22) when the resident was rolled to the left side, reached out with his right arm and fell off the mattress to the floor. Review of the Event Report submitted to the State Survey Agency on May 17, 2010, revealed that the resident struck his head on the dresser next to his bed. The physician was notified on that date and ordered the resident to be sent to the hospital for an evaluation. Review of the hospital's discharge documentation revealed that the resident sustained [REDACTED]. Review of the resident's individualized activities of daily living flow sheet for May 17, 2010, revealed that the resident's bed mobility status was a two-person assist. A statement received from the nurse aide who provided care (Employee 22), to the resident at the time of the fall, revealed that she did so without assistance from another staff member. Review of the facility's quarterly Data Collection, dated December 7, 2010, revealed that the resident continued to be a fall risk. Further review of Resident 62's clinical record revealed a nursing note, dated February 18, 2011, at 5:45 PM, which revealed that the resident was found on the floor next to this bed. Review of the facility's Event Report, dated February 18, 2011, at 5:45 PM, revealed that the resident was found lying on the floor. The bolster (a positioning device) that was to be in place while the resident was in bed, was also found on the floor. Interview with Employee 12 (Nurse Aide) on March 4, 2011, at 12:10 PM, during a demonstration of how the bolsters were placed once the resident was in bed, revealed that Employee 12 indicated that if the bolsters were applied properly, the resident would not have fallen out of bed. A review of the resident's individualized care plan for fall/falls risk initially dated May 30, 2009, revealed that the goal was that the resident would not have a fall related injury. This care plan was updated on May 17, 2010, with the problem "fell out of bed" and the intervention of "2 man assist with turning and reposition bolsters" was then added to the resident's plan of care. Interview with the Director of Nursing and the Nursing Home Administrator on March 3, 2011, at 2:10 PM, confirmed that the bolsters may not have been applied properly, which resulted in a fall. Clinical record review revealed that Resident 86 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 86 was severely, cognitively impaired, required assistance for bed mobility, transfers and ambulation and had a history of [REDACTED]. A review of an individualized care plan for fall/fall risk dated May 3, 2010, and reviewed by the facility November 20, 2010, revealed that the resident was at risk for falling and had a history of [REDACTED]. The interventions planned to prevent falls included to remind the resident and reinforce safety awareness, the use of a bed and chair alarm and floor mats beside the bed. The resident had cognitive deficits, impaired decision making skills and memory problems. A review of the resident's individualized care plan for cognitive loss dated April 2010, and reviewed by the facility November 2010, revealed that Resident 86 had impaired cognitive skills as seen by decision making problems, short and long term memory problems and dementia. There was no evidence that the facility had assessed the appropriateness and effectiveness of the planned safety intervention of reminding the resident and reinforcing safety awareness based on the resident's cognitive status. A review of an Event Report submitted to the State Survey Agency dated October 22, 2010, at 1:35 PM, revealed that a nurse aide responded to an alarm and Resident 86 was found on the floor in her room, face down with blood near her head. The physician was notified on that date and the resident was sent to the hospital. She returned to the facility with a fractured nose and 12 sutures. A review of an employee witness statement from Employee 16 (Nurse Aide) dated October 22, 2010, revealed that while this employee was picking up trays from lunch, the resident went into her room and tried to transfer herself. According to the Employee 12's written statement, "she (Resident 86) does this all day long in and out of bed by herself." A review of an employee witness statement dated October 24, 2010, at 10:00 PM, revealed that Employee 19 (Nurse Aide) revealed that the "Resident always attempts to transfer self from bed to wheelchair. She is up and down most of 3 PM to 11 PM. The resident has a bed alarm that goes off all the time." A review of an employee witness statement dated October 22, 2010, from Employee 11 (a Licensed Practical Nurse) revealed that, "Resident always climbs in and out of bed by herself." A review of an employee witness statement from Employee 22, (Nurse Aide) dated October 24, 2010, at 10:00 PM, revealed that, "This resident persists climbs in and out of bed frequently. When she returns to her room she cannot be redirected to put the call light on, ask for help or just not climb in and out of bed and wheelchair. She cannot be reasoned with secondary to dementia." The facility planned for the use of alarms to alert staff to the resident's unsafe acts but failed to identify the need and type/frequency of staff supervision required to deter unsafe acts and prevent an accident with injury. During an interview on March 3, 2011, at 9:00 AM, the Director of Nursing confirmed the lack of supervision of this resident who frequently demonstrated unsafe transfers from bed and wheelchair. She further confirmed that it could not be determined when this resident was last seen by staff prior to the fall with fracture, when she was last toileted or who was the last staff member to see her before the accident. Observation on March 1, 2011, at 6:45 PM, during the environmental tour of the 4th floor revealed Resident 86 sitting on her bed in her room. In front of her on her overbed table were two graham crackers with peanut butter (in the form of sandwich). Employee 21, a Licensed Practical Nurse, accompanying the surveyor on tour informed the surveyor that this resident would not take medication and that she crushed her evening medications and mixed them in peanut butter and placed them on the crackers. Employee 21 stated that Resident 86 never takes her medication so she has to hide them in the peanut butter. Employee 21 further stated that at approximately 5:00 PM, that evening (March 1, 2011), she crushed Vicodin (a narcotic analgesic), Remeron (an antidepressant medication), Zantac (an antiacid medication) and Risperidone (an antipsychotic medication), mixed the medications with the peanut butter and placed the cracker sandwich on the resident's bedside table and left. The resident was at dinner at the time Employee 21 placed the peanut butter and graham crackers on the resident's bedside table. The drug containing sandwich was accessible to wandering residents during the approximate hour and 45 minutes it was left at the resident's bedside. During this environmental tour at 6:45 PM, there were multiple residents ambulating in the hallway and residents with dementia reside on this floor. During an interview on March 3, 2011, at 9:00 AM, the Director of Nursing confirmed that the medication should not have been hidden in the food and left unattended at the resident's bedside. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 3/12/09, 2/12/10, 11/3/10. 28 Pa. Code 201.18(e)(1) Management. Previously cited 3/12/09, 2/12/10. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/12/09, 2/12/10, 4/21/10. 28 Pa. Code 211.12(a) Nursing services. Previously cited 3/12/09, 4/22/09, 2/12/10, 4/21/10, 11/3/10. 28 Pa. Code 211.12(c)(d)(5) Nursing services. Previously cited 3/12/09, 4/22/09, 4/27/09, 2/12/10, 4/21/10, 11/3/10. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/12/09, 4/22/09, 2/12/10.