Every finding on record at Margaret E. Moul Home

Based on facility policy, staff interview, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medication use and obtain consent prior to administering psychotropic medications for four of five residents reviewed for psychotropic medication use (Residents 1, 2, 7, and 43).Findings included: Review of facility provided policy, titled Psychoactive Drug Protocol, without implementation date, failed to reveal any expectation for providing an explanation of the risks and benefits of psychotropic medication use and obtain consent prior to administering psychotropic medications. Review of Resident 1's clinical record revealed diagnoses that included psychosis (a loss of contact with reality typically involving hallucinations, delusions and disorganized thinking) and major depressive disorder (a chronic mental health condition that can cause ongoing sadness and loss of interest). Review of Resident 1's physician orders revealed medications that included Zoloft with a start date of May 10, 2026; Remeron with a start date of June 30, 2026; and Zyprexa with a start date of July 3, 2026. Review of Resident 1's clinical record revealed no documentation of the facility's review of the risk/benefits of the medications or the receipt of consent for the use of the medications with Resident 1 or her Representative. Review of Resident 2's clinical record revealed diagnoses that included paranoid personality disorder (a mental health condition marked by a long-term pattern of deep distrust and suspicion of other people without a clear reason) and major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life). Review of Resident 2's physician orders revealed an order for Lorazepam (anxiety medication) 0.5 mg tablet given two times daily. Further review revealed an order for Haloperidol lactate (antipsychotic medication) concentrate 2 mg/ml, give 0.5 ml by mouth once daily in the morning. Review of Resident 2's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 2 or their Representative. Review of Resident 7's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and anxiety disorder (a mental health condition involving excessive, ongoing fear and worry that interfere with daily life). Review of Resident 7's physician orders revealed an order for Ability (antipsychotic medication) 10 mg tablet given orally at bedtime. Further review revealed an order for Duloxetine (antidepressant medication) 60 mg tablet given daily. Review of Resident 7's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 7 or their Representative. Review of Resident 43's clinical record revealed diagnoses that included schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia-such as hallucinations or delusions-with a major mood disorder, like depression or bipolar mania) and anxiety disorder. Review of Resident 43's physician orders revealed an order for Risperdal (antipsychotic medication) 1 mg tablet given one time daily. Further review revealed an order for Fluoxetine (antidepressant medication) 40 mg tablet given once daily. Review of Resident 43's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 2 or their Representative. Interview with the Nursing Home Administrator on August 13, 2026, at 11:05 AM, revealed that Residents 1, 2, 4, 7, and 43 did not have a consent form for the signed or the risks/benefits explained prior to starting the psychotropic medications. 211.12(d)(1)(3)(5) Nursing services

Based on observation, interview, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of 19 Residents reviewed (Resident 9).Findings include: A review of the facility procedure, titled Skin: Pressure Ulcer Irrigating, Packing, and Change of Dressing, last reviewed July 29, 2026, directs staff to do the following; after applying appropriate dressing, sign and date dressing. A review of the clinical record for Resident 9 on August 13, 2026, revealed clinical diagnoses that included stage IV right ischium pressure ulcer (lower and back part of the hip bone) and spastic quadriplegic cerebral palsy (the most serious form of cerebral palsy that causes extreme stiffness and high tone in all four limbs, the trunk, and the face). A review of Resident 9's current physician orders included an order to perform wound care to the stage IV pressure ulcer every other day, Observation of wound care on August 13, 2026, beginning at 8:30 AM, revealed the wound dressing that was removed was not dated or initialed. During an interview with Employee 3 (Licensed Practical Nurse) on August 13, 2026, at 8:45 AM, Employee 3 was asked if the dressing should have had a date and initials present, and she replied yes. During an interview with the Nursing Home Administrator (NHA) on August 13, 2026, at 11:00 AM, the NHA agreed that Resident 9's dressing should have been dated and initialed as the facility policy states. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on an observations, facility policy review, record review, and staff interviews, the facility failed to implement infection control policies regarding Enhanced Barrier Precautions for eight of 19 Residents reviewed (Residents 1, 2, 6, 7, 10, 11, 12, and 13). Findings include: Review of facility policy, Enhanced Barrier Precautions, dated July 22, 2025, read, in part, indications for use include chronic wounds and/or indwelling medical devices such as central lines regardless of MDRO (multidrug-resistant organism) status.Review of Resident 1's clinical record revealed diagnoses that included gastrostomy status (a surgical procedure that involves creating an opening in the stomach through the abdominal wall, with the placement of a feeding tube) and cerebral palsy (a neurological disorder that affects body movement and muscle coordination, typically caused by abnormal brain development or damage to the brain). Observations outside of Resident 1's room on September 2, 2025, between 9:40 AM and 12:26 PM, failed to reveal any signage indicating that Resident 1 was on enhanced barrier precautions (EBP).Observations outside of Resident 1's room on September 3, 2025, between 9:30 AM and 11:52 AM, failed to reveal any signage indicating that Resident 1 was on EBP.Review of Resident 1's physician orders failed to reveal an order to follow EBP when caring for Resident 1.Review of Resident 1's comprehensive care plan failed to reveal any mention of the need to follow EBP when caring for Resident 1.Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).Review of Resident 2's clinical record revealed that Resident 2 had a Percutaneous Endoscopic Gastrostomy tube (PEG tube - feeding tube surgically inserted into the stomach that extends through the abdomen for long term nutrition and hydration needs) and a foley catheter (tube inserted into the bladder through the urethra to facilitate the removal of urine from the bladder).During multiple observations of Resident 2's room on September 2, 2025 through September 4, 2025, failed to reveal any signage indicating that Resident 2 was on EBP.Review of Resident 2's physician orders revealed no order for EBP for Resident 2. Review of Resident 2's comprehensive plan of care revealed that EBP was not included in Resident 2's comprehensive plan of care.During observation on September 4, 2025, at approximately 9:28 AM, two Nurse Aides (Employee 4 and Employee 6) were observed in Resident 2's room. Resident 2 was observed in a wheelchair. Employee 6 was observed holding a bag of what appeared to be soiled linens. It was also observed that there was a lift in the room. When Employee 4 and Employee 6 exited Resident 2's room, Employee 4 and Employee 6 confirmed they were providing incontinence care and transferred resident to the wheelchair. Employee 4 and Employee 6 confirmed that they did not wear gowns during the care provided.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 2 on EBP.Review of Resident 6's clinical record revealed diagnoses that included dysphagia (difficulty swallowing). Observation of Resident 6's room on September 2nd, 2025, at 12:20 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident 6's care plan revealed a focus area for PEG (percutaneous endoscopic gastrostomy - a thin, flexible tube inserted through the skin of the abdomen and into the stomach) tube placement related to dysphagia. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 6. Review of Resident 6's physician orders included Glucerna 1.5 via J tube (jejunostomy tube- a surgically place tube that delivers nutrients and medication directly into the jejunum, the second part of the small intestine) 65 ml/hr until 780 ml has been infused every day via a pump, started June 9, 2023; cleanse PEG tube with normal saline solution and apply drain sponge as needed every day and evening shift, started March 4, 2025; and J/G tube medically necessary due to dysphagia, ordered February 19, 2021. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 6. Review of Resident 7's clinical record revealed diagnoses that included neurogenic bladder (a condition that occurs when the relationship between the nervous system and the bladder function is disrupted) and urinary tract infection (an infection of the urinary tract). Observation of Resident 7 on September 2, 2025, at 10:35 AM, revealed that Resident 7 had a suprapubic catheter (a flexible tube inserted into the bladder through the abdomen to drain urine). Further observation outside of Resident 7's room failed to reveal any signage indicating that Resident 7 was on EBP. Review of Resident 7's care plan revealed a care plan with a focus area of, Presence of Suprapubic Catheter. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 7. Review of Resident 7's physician orders failed to reveal an order to follow for a need to follow EBP when caring for Resident 7. Review of Resident 10's clinical record revealed diagnoses that included dysphagia. Observation of Resident 10's room on September 2nd, 2025, at 11:56 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident10's care plan revealed a focus area for PEG (percutaneous endoscopic gastrostomy - a thin, flexible tube inserted through the skin of the abdomen and into the stomach) tube placement related to dysphagia. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 10. Review of Resident 10's physician orders included Jevity1.2 (an enteral tube feeding) 95 ml/hr via gastrostomy tube until 1000 ml has been infused, started September 13, 2023; and cleanse PEG site with normal saline solution and apply drain sponge as needed every day and evening shift, started March 14, 2025. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 10. Review of Resident 11's clinical record revealed diagnoses that included neuromuscular dysfunction of bladder, history of urinary tract infections, and dysphagia. Observation of Resident 11's room on September 2nd, 2025, at 11:03 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident 11's care plan revealed a focus area for need for PEG placement related to dysphagia, and need for urinary straight catheterization multiple times a day related to neurogenic bladder with urinary retention. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 11. Review of Resident 11's physician orders included Jevity 1.5 via G tube (a tube inserted into the abdominal wall directly into the stomach to provide nutrition, fluids and medications when someone can't eat or swallow safely) 120 ml by gravity at hour of sleep, 237 ml in the morning, and 237 ml if less than 75% of lunch and dinner was consumed, started January 10, 2025; cleanse PEG site with normal saline solution and apply drain sponge as needed every day and evening shift, started March 14, 2025; and intermittent catheterization 5 times a day with 12 French catheter started September 3, 2024. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 11. Review of Resident 12's clinical record revealed diagnoses that included hypertension and stage two chronic kidney disease (mild decrease in the kidney's ability to filter toxins from the blood).Review of Resident 12's clinical record revealed that Resident 12 had a suprapubic catheter inserted (tube surgically implanted into the bladder that extends through the abdominal wall that facilitates the drainage of urine from the bladder).During multiple observations of Resident 2's room on September 2, 2025 through September 4, 2025, failed to reveal any signage indicating that Resident 2 was on EBP.Review of Resident 12's physician orders revealed that Resident 12 did not have an order for EBP.Review of Resident 12's comprehensive plan of care revealed no care plan that included the use of EBP for Resident 12 high-contact care.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 12 on EBP. Review of Resident 13's clinical record revealed diagnoses that included osteoporosis (loss in bone density) and hypertension.Review of Resident 13's clinical record revealed that Resident 13 had a PEG tube placed.Review of Resident 13's physician orders revealed that Resident 13 did not have an order for EBP.Review of Resident 13's comprehensive plan of care revealed no care plan included the use of EBP for Resident 13 during high-contact care.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 13 on EBP.Interview with the DON on September 3, 2025, at 1:30 PM, and September 4th, 2025, at 10:15 AM, it was revealed that EBP are only in place for residents with wounds, gastrostomy tubes, or catheters who have an active infection. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) appropriately, in advance of changes for Medicare covered services, to three of three residents reviewed whose Medicare coverage was discontinued (Residents 6, 9, and 66).Findings include: Review of Resident 6 clinical record documented last covered day for Medicare A services was April 10, 2025. Review of progress note dated April 8th, 2025, read, in part, a message was left for Resident 6's parents stating the Medicare services will end on April 10th, 2025, and on April 11th, 2025, she will evert back to Medicaid. Notice of Medicare Non-Coverage (NOMNC) was mailed to Resident 6's parents. The facility provided a copy of the signed NOMNC, which was dated April 11th, 2025. Review of Resident 9's clinical record documented last covered day for Medicare A services was May 6, 2025. Review of progress note, dated May 2nd, read, in part, Resident 9 was notified that his Medicare services will end on May 6th, 2025, and on May 7th, 2025, he will evert back to Medicaid. The Resident had no further questions. The facility provided a copy of the signed NOMNC, which was dated May 2nd, 2025. Review of Resident 66's clinical record documented last covered day for Medicare A services was May 26, 2025. Review of progress noted dated May 23rd, 2025, read, in part, Resident 66 was notified that his Medicare services will end on May 26th, 2025, and on May 27th, 2025, he will evert back to Medicaid. The Resident had no further questions. The facility provided a copy of the signed NOMNC, which was dated May 23rd, 2025. Interview with Employees 1 and 2 on September 4th, 2025, at 11:48 AM, revealed the facility wasn't utilizing the Center for Medicaid/Medicare Services SNF ABN form as of January 2025. It was revealed that they were informed regarding an update to the NOMNC form January 2025 and assumed the SNF ABN form was no longer required. Interview with the Nursing Home Administrator on September 4, 2025, at 12:16 PM, revealed the SNF ABN form should've been completed. 28 Pa. Code 201.29(c.3)(1) Resident rights

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Review of facility policy, titled Labeling and Dating last reviewed September 2, 2025, read, in part, All food items must be labeled and dated. All food items must be labeled with either a manufacturer label or handwritten label.Review of facility policy titled Purchasing Policy- Storage last reviewed September 2, 2025, read, in part, all items in refrigerators and freezers must be properly wrapped, labeled, and dated.Observation in the dry storage area on September 2, 2025, at 9:57 AM, revealed one open bag of macaroni pasta without an open date; one open bag of penne pasta without an open date; two bags of angel hair pasta not dated; one bag of open powdered sugar not labeled or dated; and one bag of candy topping not labeled or dated.Observation in the walk-in refrigerator on September 2, 2025, at 9:59 AM, revealed one package of vegan cheese left open to air not properly sealed; one container of mozzarella cheese left open to air not properly sealed; two packages of meat revealed to be turkey breast not labeled or dated; one bag of spinach not dated; one bag of parsley not dated; two bags of broccoli not dated; one open container of sour cream open without an open date; and one bag of whipped cream open and not dated.Observation in walk-in freezer unit on September 2, 2025, at 10:04 AM, revealed two packages of zucchini fries not dated; two bags of waffles not dated with one left open to air not properly sealed; and two packages of hot dogs not dated. Observation in the main kitchen on September 2, 2025, at 10:08 AM, revealed a blank temperature log from July 2025 on the wall overtop of the three-compartment sink. Observation in the three-compartment sink on September 2, 2025, at 10:09 AM, revealed dirty pans in the wash section, and the sanitizer sink filled with water and sanitizing solution. Employee 3 (FSD- Food Service Director) tested the sanitizer concentration with testing strips. The surveyor checked the expiration date on the strip container used to test the concentration of the sanitizer, and it revealed an expiration date of May 1, 2024.Interview with Employee 3 on September 2, 2025, at 10:14 AM, revealed he would expect labeling and dating per facility policy, and he would be reaching out to their supplier for new test strips. Return visit to the main kitchen on September 3, 2025, at 11:37 AM, revealed the blank temperature log from July 2025 remained on the wall overtop of the three-compartment sinkInterview with Employee 3 on September 3, 2025, at 11:38 AM, revealed the concentration of the sanitizer solution did not get logged from the morning of September 2, 2025, and that there are no logged sanitizer solution concentration measures since July 2025. Interview with the Nursing Home Administrator on September 3, 2025, at 1:20 PM, revealed it is his expectation that food items are labeled and dated per facility policy, and kitchen equipment is utilized in accordance with professional standards.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 19 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included gastrostomy status (a surgical procedure that involves creating an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube) and cerebral palsy (a neurological disorder that affects body movement and muscle coordination, typically caused by abnormal brain development or damage to the brain). Review of Resident 1's physician orders revealed an order for Bilateral hand rolls worn when OOB (out of bed). Don/Doff by (Nurse Aide), with a start date of April 24, 2024.Review of Resident 1's comprehensive care plan revealed a focus area of Impaired Mobility with potential for contractures (structural changes to your soft and connective tissues that cause them to stiffen, tighten and contract) related to diagnosis cerebral palsy with an intervention for Bilateral hand rolls when out of bed, with a start date of April 22, 2024. Observations of Resident 1 on September 2, 2025, between 9:40 AM and 12:26 PM, revealed he was sitting in his wheelchair and did not have bilateral hand rolls in his hands. Observations of Resident 1 on September 3, 2025, between 9:30 AM and 11:52 AM, revealed he was sitting in his wheelchair and did not have bilateral hand rolls in his hands. Review of Resident 1's clinical record revealed a nurse aide task Apply or remove- Bilateral hand rolls worn when OOB. Further review of the aforementioned nurse aide task revealed documentation to indicate Employee 4 (Nurse Aide) donned the bilateral hand rolls on Resident 1 on September 3, 2025, at 8:48 AM.Interview with Employee 5 (Licensed Practical Nurse) on September 3, 2025, at 12:00 PM, revealed she was unsure as to why Resident 1 did not have his bilateral hand rolls in place, and she was unable to find them in his room. Interview with the Director of Nursing (DON) on September 4, 2025, at 10:06 AM, she revealed Employee 4 stated she put the hand rolls on that morning but then took them off for care and forgot to put them back on, and that an employee from the therapy department went back to the room later that day and found the hand rolls in Resident 1's top drawer in his room. During an email correspondence with the Nursing Home Administrator on September 4, 2025, at 10:53 AM, he revealed his expectation that the bilateral hand rolls would be applied following the physician orders. 28 Pa. Code 211.10 (a) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide once every 12 months for five of five nurse aide employee files reviewed (Employees 1-5). Findings Include: A performance evaluation or appraisal is defined as a tool to document an employee's performance over time. A review of Employee 1's information revealed a hire date of May 22, 2023. A review of Employee 1's training information revealed no annual performance evaluation. A review of Employee 2's information revealed a hire date of January 18, 2021. A review of Employee 2's training information revealed no annual performance evaluation. A review of Employee 3's information revealed a hire date of April 17, 2017. A review of Employee 3's training information revealed no annual performance evaluation. A review of Employee 4's information revealed a hire date of February 20, 2006. A review of Employee 4's training information revealed no annual performance evaluation. A review of Employee 5's information revealed a hire date of April 21, 2008. A review of Employee 5's training information revealed no annual performance evaluation. An interview with the Nursing Home Administrator on August 27, 2024, at 10:22 AM, confirmed the facility has not completed annual performance evaluations on those nurse aides. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 49 and 74). Findings include: Review of Resident 49's clinical record revealed diagnoses that included severe intellectual disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and spastic quadriplegia cerebral palsy (cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination. Spastic quadriplegia cerebral palsy is a form of cerebral palsy that affects both arms and legs and often the torso and face). Review of Resident 49's quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated July 29, 2024, revealed that in Section K, it was marked no or unknown for a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Review of Resident 49's clinical record revealed a weight of 83 pounds on July 29, 2024, and a weight of 98.4 pounds on January 17, 2024, which is a 15.65% weight loss in 6 months. Review of Resident 49's nutrition progress note dated August 1, 2024, revealed that Resident 49's weight was down 10% in 180 days. During an interview with the Nursing Home Administrator (NHA) on August 28, 2024, at 11:49 AM, he confirmed that Resident 49's quarterly MDS was a coding error and that her weight loss should have been coded on the MDS. A review of the clinical record for Resident 74 on revealed diagnoses that include spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder that affects all four limbs, the trunk, and the face) and Unspecified Psychosis (condition that affects the mind and makes it hard to tell what is real and what is not. It can cause delusions, hallucinations, and disorganized speech or behavior). A review of Resident 74's Quarterly MDS dated [DATE], revealed that Section H. Bladder and Bladder, Subsection H0100. Appliances. A. was marked yes for an indwelling catheter. Observation of Resident 74 while in bed on August 25, 2024, at 10:00 AM, failed to reveal any catheter bag or tubing hanging on the side of his bed. During an interview with Employee 6 (Licensed Practical Nurse) on August 26, 2024, at 10:15 AM, Employee 6 informed the surveyor that Resident 74 never had an indwelling catheter. Employee 6 informed the surveyor that Resident 74 wears a condom catheter (a non-invasive device that can be used to collect urine and is considered an alternative to incontinence pads) that is connected to a urine drainage bag when the Resident is out of bed. During an interview with the NHA on August 27, 2024, at 2:00 PM, the NHA confirmed that Resident 74's June 14, 2024, MDS was marked in error for an indwelling catheter. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 5 and 14). Findings Include: Review of Resident 5's clinical record revealed diagnosis that included cerebral palsy (weakness or problems with using the muscles) and hypertension (high blood pressure). Review of Resident 5's MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated July 21, 2023, revealed that section J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment, was marked 0, No. Review of a fall incident report dated June 24, 2023, at 11:45 AM, revealed Resident 5 had a fall in their room. Review of Resident 5's clinical nursing progress notes revealed a progress note dated June 24, 2023, at 1:09 PM, revealed that the Resident was found sitting on the floor with their back against the bed frame and feet extending in front of them. Review of Resident 5's MDS dated [DATE], revealed that section N0410. Medications Received (B. Medication received: Days: Antianxiety) was marked 0, indicating Resident 5 has not received any antianxiety medications in the last seven days of when the assessment was completed. Review of Resident 5's July 2023 Medication Administration Record revealed that Resident 5 received Lorazepam Tablet 0.5 Milligram two times a day for the entire month. Further review of Resident 5's current Medication Review Report revealed that the Resident is prescribed Lorazepam Tablet 0.5 milligram two times a day, with a start date of March 31, 2021. During an interview with the Nursing Home Administrator on October 25, 2023, at 1:53 PM, he confirmed that the fall that occurred on June 24, 2023, and the antianxiety medication not being captured on the MDS completed on July 21, 2023, were both errors and they have both been fixed. Review of Resident 14's clinical record revealed diagnoses that included thoracic spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly) with hydrocephalus (a build-up of fluid in the cavities deep within the brain), hypertension, and major depressive disorder. Review of Resident 14's quarterly MDS assessment dated [DATE], revealed that in section H, Resident 14 was coded as having an indwelling catheter (a catheter that is maintained within the bladder for the purpose of continuous drainage of urine). Further review of the MDS revealed that intermittent catheterization (insertion and removal of a catheter through the urethra for bladder drainage) is not marked, and urinary continence is coded as 9- not rated. Review of Resident 14's current physician orders revealed an order dated August 4, 2023, for intermittent straight catheterization twice a day. Further review of Resident 14's clinical record failed to reveal any evidence that Resident 14 had an indwelling catheter at any time in the seven days prior to, and including, September 29, 2023. During an interview with the Director of Nursing (DON) on October 26, 2023, at 10:52 AM, she stated that the Resident does receive intermittent catheterization twice daily, and that Resident 14 is also sometimes incontinent of urine. In a follow-up interview with the DON on October 26, 2023, at 11:18 AM, she stated that Resident 14 did not have an indwelling catheter at any time around September 29, 2023, and stated that the MDS assessment was incorrectly coded and a modification would be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure care and services were provided to ensure residents attain and maintain the highest practicable level of health for one of 18 residents reviewed (Resident 64). Findings include: Review of Resident 64's clinical record on October 19, 2021, at approximately 9:30 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 64's clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack a small amount of Alginate Rope into wound bed to help manage drainage. Please leave at least 3/4 wick out with packing to ensure easy removal of rope. No cover dressing. Change (apply skin prep to peri wound), dated August 2, 2021. During wound dressing observation on October 20, 2021, at approximately 11:10 AM, Registered Nurse (RN) 1 was observed retrieving a bag of treatment supplies from a treatment cart. At approximately 11:15 AM, RN 1 was observed removing treatment supplies from the bag. Observation of the package containing the Alginate Rope, revealed it was opened upon removal from the bag. Review of the manufacturer's package for the Alginate Rope revealed that on the package it stated, Sterilized Using Irradiation .Do Not Use If Damaged, and Do not reuse. During the dressing change, RN 1 was observed retrieving the Alginate Rope from the open package, cutting a piece of the dressing and then packing the dressing into Resident 64's wound. After the wound dressing was completed, RN 1 replaced the Alginate Rope in the package and returned the package to the bag along with other unused treatment supplies. The entire bag of treatment supplies was then returned to the treatment cart. During a staff interview on October 21, 2021, at approximately 11:45 AM, Nursing Home Administrator revealed that, after review of the manufacturer's packaging for the Alginate Rope dressing, excess Alginate Rope dressing should be discarded, and a new package should be utilized with each dressing change. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility's written notification to the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman regarding resident transfers failed to include all of the following information; the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for 8 of 18 resident records reviewed (Residents 6, 16, 55, 63, 64, 67, 71, and 78 ). Findings include: Review of Resident 6's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 6's clinical record revealed a transfers to the hospital on July 7, 2021, and admitted with pneumonia (lung inflammation caused by bacterial or [CONDITION(S)] infection in which the air sacs fill with pus and may become solid), and on September 28, 2021, and was admitted with [CONDITION(S)] (the inflammation of the lining of the colon). Review of the Resident 6's Notices of Transfer dated July 7, 2021, and September 28, 2021 failed to contain the contact information for the Office of the State long-Term Care Ombudsman. Review of Resident 16's clinical record revealed spastic [CONDITION(S)] [CONDITION(S)] (a condition marked by impaired muscle coordination and loss of use of the whole body caused by damage to the brain before or at birth), [CONDITION(S)] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness or convulsions associated with abnormal electrical activity in the brain), paralytic ileus (a condition is which the muscles of the intestines don't allow food to pass through), and dysarthria (a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking, resulting in slurred or slow speech). Further review of Resident 16's clinical record revealed a transfer to the hospital on August 3, 2021 for pneumonitis (inflammation of the walls of the alveoli in the lungs, usually caused by a virus), and September 24, 202, for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 16's Notices of Transfer dated August 4, 2021, and September 27, 2021 failed to contain the contact information for the Office of the State long-Term Care Ombudsman. Review of Resident 55's clinical record revealed a hospital transfer on October 3, 2021. Review of Resident 55's Notice of Transfer form revealed no contact information for the Office of the State Long-Term Care Ombudsman. Review of Resident 63's clinical record on October 18, 2021, at approximately 1:30 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 63's clinical record revealed that Resident 63 was transferred out of the facility to a hospital on June 16, 2021, July 31, 2021, and August 17, 2021. Review of the Resident 63's Notice of Transfer dated June 16, 2021, and August 17, 2021 failed to contain the contact information for the Office of the State Long-Term Care Ombudsman. Further, a notice was not provided for the transfer that occurred on July 31, 2021. During a staff interview on October 21, 2021, at approximately 11:45 AM, Nursing Home Adminstrator revealed that, after review, Resident 63 should have received a notice of transfer for the July 31, 2021 transfer. Review of Resident 64's clinical record on October 19, 2021, at approximately 9:30 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 64's clinical record revealed that Resident 64 was transferred to the hospital on September 9, 2021. Review of Resident 64's Notice of Transfer dated September 9, 2021, revealed it failed to contain the contact information for the Office of the State Long-Term Care Ombudsman. Review of Resident 67's clinical record on October 19, 2021, at approximately 11:00 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 67's clinical record revealed that Resident 64 was transferred to the hospital on August 31, 2021, and September 25, 2021. Review of Resident 67's Notice of Transfer for the aforementioned hospital transfers revealed they failed to contain the contact information for the Office of the State Long-Term Care Ombudsman. Review of Resident 71's clinical record on October 18, 2021, at approximately 1:30 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 71's clinical record revealed that Resident 71 was transferred to the hospital on August 16, and 25, 2021, and September 19, 2021. Review of Resident 71's Notice of Transfer for the aforementioned transfers to the hospital revealed they failed to contain the contact information for the Office of the State Long-Term Care Ombudsman. Review of Resident 78's clinical record revealed a hospital transfer on October 12, 2021. Review of Resident 78's Notice of Transfer form revealed no contact information for the Office of the State Long-Term Care Ombudsman. During an interview with the Nursing Home Administrator on October 20, 2021, at approximately 12:12 PM it was revealed that the facility Notice of Transfer form does not include the contact information for the representative of the Pennsylvania State Ombudsman office. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of select facility documentation and policy as well as staff interview, it was determined that the facility failed to follow the Centers for Disease Control and Prevention (CDC) recommended practices for management of healthcare personnel exhibiting possible signs and symptoms of COVID for two of 18 staff members who tested positive for COVID-19 (LPN1(Licensed Practical Nurse) and NA1(Nurse Aide)). The findings include: According to CDC guidelines for Preparing for COVID-19 in Nursing Homes at cdc.gov, Evaluate and Manage Healthcare Personnel .As part of routine practice, ask HCP (Healthcare Personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. If HCP develop fever (T=100.0oF) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). HCP with suspected COVID-19 should be prioritized for testing. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. According to CDC guidance on Symptoms of Coronavirus at cdc.gov, People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: · Fever or chills · Cough · Shortness of breath or difficulty breathing · Fatigue · Muscle or body aches · Headache · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea This list does not include all possible symptoms. Review of facility policy, COVID-19 Addendum to MEMH Infection Control Manual revealed, The primary goal of MEMH is to prevent COVID-19 from being introduced within our Home. Prevention efforts include .Reminding employees to stay home if they are experiencing fever and respiratory symptoms .Monitoring residents (current and new admissions) and employees for fever or respiratory symptoms, such as, cough, or shortness of breath. If symptoms are identified, move to actions steps to prevent the spread of respiratory germs within the MEMH .The facility has a plan for monitoring and assigning work restrictions for ill and exposed HCP. All ill HCP are encouraged to stay home, and all HCP are required to complete daily screening including temperature checks, when in the facility. If indicated in screening - they are sent home. Review of facility line listing of staff members who tested positive for COVID-19, revealed LPN 1 was tested for COVID-19 on October 15, 2020, and was found to be positive for [MEDICAL CONDITION] on October 19, 2020. Review of LPN1's timesheets revealed that she worked at the facility on October 14, 15, 16, and 17, 2020. Review of LPN1's daily screening forms (completed at the start of each shift) for those dates revealed that she reported she was experiencing a cough and sore throat on October 14, 2020, a cough on October 15, 2020 and a cough on October 16, 2020. Review of facility line listing of staff members who tested positive for COVID-19 revealed NA 1 was tested for COVID-19 on October 22, 2020, and was found to be positive for [MEDICAL CONDITION] on October 24, 2020. Review of NA1's timesheet revealed that she worked at the facility on October 21, 2020. Review of her screening form for that date revealed that she reported she was experiencing a sore throat at the start of her shift. During an interview with the Nursing Home Administrator (NHA) on November 4, 2020, at approximately 10:50 AM, he revealed that all screening forms were reviewed by the infection control Preventionist and the symptoms that raised red flags were elevated temperatures and loss of taste or smell. If these were indicated, a rapid COVID test would have been done or the staff person would be advised to go to urgent care or their healthcare provider for follow-up. Email correspondence received from the NHA on November 5, 2020, at 1:38 PM revealed that the infection Preventionist did talk to LPN1 about how she was feeling during those initial days when she was having some headaches and fatigue, and a sore throat which was coming and going. She never developed a high temperature, and on her screening forms her self-reported symptoms were improving. Because her symptoms were improving or going away, she was permitted to work. During an additional interview with the Nursing Home Administrator on November 5, 2020, at approximately 3:00 PM, he revealed that at the time LPN1 and NA1 were experiencing symptoms, surveillance was just being done at that point since the facility had not had any positive COVID cases, universal masking was in place since the end of March or early April, and weekly universal testing of the staff was being conducted. He also revealed that from the beginning staff had been educated to stay home when ill and report any symptoms that were concerning to them since some symptoms could have been attributed to allergies [REDACTED]. The NHA noted that there is a significant difference in COVID surveillance/testing and an outbreak response which is a much more focused approach. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of select facility documentation and staff interview, it was determined that the facility failed to provide evidence that the required notices to the resident or the resident's representative following the end of their Medicare coverage were provided for three of three residents reviewed who remained in the facility for long-term care (Residents 58, 75 and 76). Findings include: Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, partially completed by the facility indicated that Resident 58 would no longer receive Medicare Part A Coverage starting December 24, 2019, included information regarding potential costs, and did not contain any signatures or dating of acknowledgement of receipt from resident or resident representative. Review of an Advanced Beneficiary Notice of Non-coverage regarding Resident 58 also revealed a partially completed form which indicated that Medicare Part a services would end on December 23, 2019, and did not contain any signatures or dating of acknowledgement of receipt from resident or resident representative. Review of Resident 58's progress notes revealed a note dated for December 19, 2019, that a Letter of Notice of Medicare Non-coverage and (SNFABN) was given to (Resident) and mailed to her sister . (sister's name) today. Last date of Medicare 12-23-19. Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, partially completed by the facility indicated that Resident 75 would no longer receive Medicare Part A Coverage starting September 27, 2019, included information regarding potential costs, and did not contain any signatures or dating of acknowledgement of receipt from resident or resident representative. Review of an Advanced Beneficiary Notice of Non-coverage regarding Resident 75 also revealed a partially completed form which indicated that Medicare Part a services would end on September 26, 2019, and did not contain any signatures or dating of acknowledgement of receipt from resident or resident representative. Further review of this form revealed a handwritten note Letter mailed to (name of resident's representative) 9/24/19 also called (name of resident's representative) to notify by phone with a dated signature of 9/24/19. Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, partially completed by the facility indicated that Resident 76 would no longer receive Medicare Part A Coverage starting February 8, 2020, included information regarding potential costs, and did not review any signatures or dating of acknowledgement of receipt from resident or resident representative. Review of an Advanced Beneficiary Notice of Non-coverage regarding Resident 76 also revealed a partially completed form which indicated that Medicare Part a services would end on February 7, 2020, and did not reveal any signatures or dating of acknowledgement of receipt from resident or resident representative. Review of Resident 76's progress notes revealed a note dated for February 5, 2020, which revealed (resident's name) was given his cut letters for Medicare. His Medicare will end on 2720. Facility did not provide any additional information to confirm that Residents 58, 75 and 76 or their representatives were explained the information contained in the forms regarding their discontinued services. During an interview with Nursing Home Administrator (NHA) on March 5, 2020, at approximately 11:50 AM the NHA revealed the expectation that the forms would be completed to include information regarding resident/resident representative acknowledgement of the information. 28 Pa. Code 201.18(e)(1) Management.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to maintain an acceptable parameter of nutritional status for one of 17 residents reviewed receiving tube feedings (Resident 65). Findings include: Review of the clinical record for Resident 65 revealed [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of tube feeding intakes revealed that 14 out of 19 days reviewed, Resident 65 received less than 948 ml. Review of the nutrition assessment performed by the dietician on March 3, 2020, revealed that the resident needs 1200 calories (Cal) and with the current tube feed order she is receiving 1137. Review of the product information sheet for [MEDICATION NAME] 1.2 revealed that to meet 100% of RDI (recommended daily intake) (the quantity of a particular nutrient which should be consumed daily in order to maintain good health) for 24 essential vitamins and minerals in 1200 Cal (1 liter). During an interview with the Dietician on March 5, 2020 at 10:42 AM she confirmed that the resident needs 1200 Cal and is receiving 1137. She also confirmed that there were days that the resident received less than the ordered amount of tube feed. During an interview with the Nursing Home Administrator and Director of Nursing on March 5, 2020 at 11:40 PM they acknowledged the need for the essential vitamins and minerals. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, review of facility policies, and interviews with staff it was determined that the facility failed to store food properly and that staff failed to employ hygienic procedures while bussing dining room in accordance with professional standards for food safety. Findings include: During completion of facility main kitchen entrance tour on March 2, 2020, with Dietary Manager (DM) 1 the observation was made in walk-in freezer at 9:47 AM of four small boxes of collard greens out of original case box with no identifying information for date of being received. Also observed were one large bag of cauliflower, one large bag of diced carrots, one large bag of peas, one large bag mixed vegetables, one small bag yellow beans and one medium size bag stirfry blend vegetables which were all out of original case box and not dated with received date. During an interview with DM 1 during this observation , DM 1 stated that she didn't think that frozen vegetables had to be labeled when they were out of the case box. The facility failed to ensure that frozen vegetables were dated with receipt date upon removing from original case boxes (original case boxes have this information attached). The facility bussing cart contained cleaning supplies/clean gloves stored in close proximity to dirty dishware and trash. Continuation of the kitchen entrance tour revealed observation, while accompanied with DM 1, at 10:02 AM of small foodservice stainless steel three tiered cart in the kitchen, near the door leading into the dining room. It was observed that stored on the three shelves were bussing tubs containing dirty dish/glassware from the breakfast meal. It was observed that one end of the cart had an attached trash receptacle with plastic liner and contained paper trash and some discarded food items. It was observed that the other end of the cart had also an attached clean trash receptacle and contained boxes of gloves and wipes for cleaning tables. At this time, DM 1 was advised as to concern regarding clean items being in close proximity to contaminated items. Observation in facility main dining room on March 2, 2020, at 12:08 PM revealed that the bussing cart did not contain the clean gloves/wipes. Dietary aide (DA) 1 was observed utilizing the cart at this time wearing gloves. DA 1 was observed at this time to be clearing used plates and glassware from resident tables and was observed to touch her face to the side of her gloved hand, she then walked around and picked up a few used glasses, put them in bin on bussing cart, touched the same gloved hand several times to the top of the trash bag (containg food/paper trash), then stepped to the nearby table and put her same gloved hand full across on the top of a small plastic food product container. DA 1 was then observed to walk across the dining room and put this container into a cupboard. Observation was made at 12:20 PM that DA 1 started pulling off her gloves, stopped halfway off, then reached for clean ones which she held in her hands before completely removing the dirty ones to put in the trash, at which time she put on the clean gloves. Observation was made at 12:28 PM that DA 1 removed one of the trash bags from the dirty cart then opened a clean bag using the same gloves. DA 1 was observed to remove the dirty gloves at this time and wash her hands. Observation was made at 12:35 PM that DA 1 made another glove change without washing hands. Observation was made that DA 1 continued her tasks of removing used items from tables (it was noted that when she removed glasses she did so by grasping the rim). Observation was made that while wearing dirtied gloves she pulled clean wipes, wadded them into her dirtied gloves, and then used them to wipe a table. Observation was made in main dining room on March 4, 2020, of DA 1 performing her tasks during breakfast meal. On this date it was noted that one end of the bussing cart contained a plastic bag liner and there was one container of clean wipes in it. DA 1 was observed to bus some items from a table which included a glass with a significant amount of milk in it which she poured over the one handle of the bussing cart into the lined trash container on the other end. Review of facility Hand Washing 101 policy (not dated) revealed under When should you wash your hands? line F before putting on food service gloves. Review of policy for Bare hand contact with food revealed Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damage or soiled, or when interruptions occur in the operation and also Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed . After handling soiled trays or dishes. After handling anything soiled and during food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Except for two observations, DA 1 failed to consistently wash hands with glove changes and also failed to change gloves at times she should have when her task changed. During an interview with Nursing Home Administrator (NHA) on March 4, 2020, at 3:35 PM the NHA revealed the expectation that the bus cart would not have had dirty and clean items on same cart, would not expect staff to mix dirty tasks with clean without changing gloves/hand washing, and that the frozen vegetables would be dated. 28 Pa code 211.6(b)(d) - Dietary Services

Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise the care plan for one of 20 residents reviewed (Resident 26). Findings include: Review of the clinical record for Resident 26 revealed [DIAGNOSES REDACTED]. On February 25, 2020, an ulcer wound sheet was initiated by Registered Nurse (RN) 2, identifying the area on the right ischial as a stage 1 pressure ulcer. The treatment to the area was documented as [MEDICATION NAME] (a barrier cream designed to heal cuts and wounds) with care. Another ulcer skin sheet dated March 3, 2020 also indicated that the treatment was [MEDICATION NAME] with care. Review of the current facility policy titled, skin care treatment protocol guideline states that treatment options for a stage 1 pressure ulcer is skin prep per nursing judgment. Review of the care plan and resident care profile (reference for nurse aids) revealed that [MEDICATION NAME] application was not on the care plan or care profile. During an interview with the Director of Nursing on March 5, 2020 at 11:43 AM she confirmed that the [MEDICATION NAME] cream should have been on the care profile. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 20 residents reviewed (Resident 71). Findings include: Review of Resident 71's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 71's annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated November 22, 2019 and modification of quarterly MDS, dated [DATE], both revealed that in section I, Resident 71 was coded as having pneumonia. Review of Resident 71's clinical record failed to reveal any evidence that Resident 71 was treated for [REDACTED]. During an interview with Licensed Practical Nurse (LPN) 1 on March 5, 2020, at 9:22 AM she stated that Resident 71 has not had any infections recently and it has been a while since she had pneumonia. On March 5, 2020, at 10:36 AM the Registered Nurse Assessment Coordinator (RNAC) stated that both of the MDS's were marked in error for pneumonia and stated that pneumonia should not have been coded. On March 5, 2020, at 11:46 AM the Director of Nursing stated that both of the MDS's have been corrected. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure residents using [MEDICAL CONDITION] medications received a gradual dose reduction for one of five residents reviewed for unnecessary medications (Resident 45). Findings Include: Review of Resident 45's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 45's current physician orders [REDACTED]. Review of Resident 45's form titled Psychoactive Medication Monitoring Form revealed that Resident 45 has been receiving a total of 2 mg of [MEDICATION NAME] per day, since February 2, 2015. Review of Resident 45's facility form titled Mood/Behavior/Psychoactive Drug Assessment, dated January 20, 2020, reviewing the time period of October 29, 2019-January 20, 2020, revealed that Resident 45 did not have any behaviors during those months. Review of Resident 45's behavior monitoring, delusion monitoring and hallucination monitoring, dated February 4, 2020-March 4, 2020, revealed Resident 45 did not display any behaviors, delusions or hallucinations during that time. Review of Resident 45's Behavior Management Plan, with an updated date of October 15, 2019, revealed Resident 45 has experienced decline in health which has decreased his level of activity and degree of interaction with others. There has been a significant reduction in target behaviors. Review of Resident 45's psychiatric consultation dated May 28, 2019, revealed Behavioral report looks good re: impulsive behaviors & depression. Staff have not expressed any concerns. Review of Resident 45's psychiatric consultation dated August 28, 2019, revealed excellent behavioral report. Review of Resident 45's psychiatric consultation, dated January 6, 2020, revealed that facility staff asked if Resident's [MEDICATION NAME] could be decreased due to increased sleepiness. A new order was received to change the dosing of the [MEDICATION NAME] from 1 mg twice a day to 0.5 mg in the morning and 1.5 mg at night, so Resident 45 would still be receiving 2 mg total per day. During an interview with Licensed Practical Nurse (LPN) 1, who is part of the facility's behavior team, on March 4, 2020, at 10:06 AM she stated that Resident 45 has had a lot of medical decline over the past year or two and his behaviors have gotten better and it has been a while since he's had an outburst. She stated that due to Resident's health decline, she feels that Resident wouldn't be capable of displaying the same aggressive behaviors he once displayed. She stated the facility has consulted with his psychiatrist about decreasing the [MEDICATION NAME] but that provider has declined to do so. LPN 1 stated that Resident 45 has a follow up psychiatric appointment in April and the facility will again make the recommendation to try a gradual dose reduction of Resident 45's [MEDICATION NAME]. On March 5, 2020, at approximately 11:50 AM the Nursing Home Administrator and Director of Nursing were made aware of the above. At approximately 1:15 PM the Director of Nursing confirmed that Resident 45 has been receiving 2 mg of [MEDICATION NAME] since February 2, 2015 and stated that he goes for another psychiatric appointment in April. She stated that Resident 45's provider from the facility defers to Resident 45's psychiatric provider regarding the [MEDICATION NAME]. 28 Pa. Code 211.2(a) Physician services.

Based on a review of employee personnel files, clinical records and select facility policy and staff interview it was determined that the facility failed to ensure that a licensed nurse demonstrated competency in the necessary skills and resident care tasks to meet resident needs as evidenced by one licensed nurse (Employee 1) out of two files reviewed. Findings include: Review of the clinical record for Resident 26 revealed [DIAGNOSES REDACTED]. Review of current faciltiy policy titled Skin care treatment protocol guideline, defines a pressure injury (ulcer) as localized damage to the skin and underlying tissue usually over a bony prominence. The injury can present as intact skin or an open ulcer. The injury occurs as a result of intense or prolonged pressure. The policy defines a stage 1 pressure injury as non blanchable (the skin does not turn white when touched with a finger) [DIAGNOSES REDACTED] (redness) of intact skin. Further review of the clinical record for Resident 26 revealed a skin sheet dated February 16, 2020 that identified an reddened area 2 cm x 0.8 cm on the right ischial (the bony protrusion which takes the body ' s weight during sitting). On February 25, 2020 an ulcer wound sheet was initiated by Registered Nurse (RN) 2, identifying the area on the right ischial as a stage 1 pressure ulcer. The size and description were noted as 1.6 cm x 0.8 cm, red and blanching. On March 3, 2020, another assessment was completed by RN 2 describing the area on the right ischial as a stage 1 pressure ulcer. The size and description were noted as 1.5 cm x 0.8 cm, pink, blanching and intact. On March 5, 2020 at 9:28 PM, Licensed Practical Nurse (LPN) 2 assessed Resident 26's right ischial. When LPN 2 pressed on the reddened area the skin blanched. The are was also intact. According to the facility policy and NCBI national pressure ulcer staging system a stage 1 pressure ulcer needs to be intact skin with nonblanchable redness. Observation of the wound on March 5, 2020, in the presence of LPN 2, the wound was blanchable. Therefore, the wound would not meet the definition of a pressure ulcer. During an interview with the Director of Nursing on March 5, 2020 at 1:20 PM she stated that RN 1 did not have any specialized training for wound care but does attend a seminar annually. She confirmed that there are no competencies done for wound care. 28 Pa. Code 201.18 (e)(1)(2)(3) Management 28 Pa. Code 201.20 (a) Staff Development

Based on observations, review of policy and interview with staff, it was determined that the facility failed to ensure food was served in accordance with professional standards for food safety in the main kitchen. Findings Include: Review of the policy, Handwashing and Proper Glove Use, reflects that employees must wash hands and change gloves every time they change tasks or start working with new food items. Observations on (MONTH) 18, 2019, at approximately 11:15 AM, revealed Cook 1 wearing disposable gloves and serving food items on tray line. Cook 1 then proceeded to the refrigerator and opened the door with gloved hands, reached in and pulled out approximately 2 ounces of chipped ham/turkey with the same gloves. Cook 1 proceeded to shut the refrigerator door. Cook 1 proceeded to the prep table and pulled the pieces of ham and turkey apart with the same gloved hands he used to open the refrigerator door. An interview on (MONTH) 18, 2019, at approximately 2:25 PM with the Director of Nursing and the Nursing Home Administrator, confirmed that Cook 1 should have washed his hands and changed gloves after touching the refrigerator door and before touching food. An interview with the Food Service Manager, on (MONTH) 19, 2019, at approximately 10:15 AM revealed Cook 1 should have changed gloves prior to touching food items. 28 Pa. Code 211.6 (b) (d) Dietary services

Based on review of the clinical record, facility documentation and staff interview, it was determined that the facility failed to provide care and services in accordance with each residents' comprehensive plan of care for one of 8 residents reviewed (Resident 4), resulting in harm to the resident. Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. Review of the facility's Incident Report dated May 25, 2015, revealed that Resident 4 suffered a fall at 9:00 a.m., on that date, and sustained a laceration to his right eyebrow area. The resident was transferred to the hospital for evaluation of head trauma. Review of Resident 4's clinical record, Resident Care Profile (information on resident care needs) revealed that Resident 4 was to have 2 person assistance for transfers, bed mobility and bathing. Review of the facility documentation revealed that at the time of Resident 4's fall, incontinent care was being provided by one nurse aide. The report states that she turned him (the resident) away from her to provide care and he tumbled out of bed, onto the floor, where he hit his head. Following the fall, the report indicated that the nurse aide picked Resident 4 up from the floor, put him back in bed, then transferred him to the shower bed, without assistance. In an interview with the Nursing Home Administrator on September 18, 2015 at 1:00 p.m., she confirmed that the care plan for Resident 4 was not followed at the time of the aforementioned fall and that it is the facility's expectation that care and services are provided to residents in accordance with their comprehensive plan of care. Refer to F323. CFR 483.20(k)(3)(ii) Services by Qualified Persons/per Care Plan. Previously cited 04/17/14. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 04/17/14. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/14/15, 04/17/14.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the residents received adequate supervision and assistance to prevent accidents for two of 8 residents reviewed (Residents 4 and 5) resulting in harm to both residents. Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. Review of the facility Incident/Accident Report dated May 25, 2015, revealed that Resident 4 suffered a fall at 9:00 a.m., on that date. Resident 4 sustained a laceration to his right eyebrow area and was transferred to the hospital for evaluation of head trauma. Review of Resident 4's clinical record, Resident Care Profile (information on resident care needs) revealed that Resident 4 was to have 2 person assistance for transfers, bed mobility, and bathing. Review of the aforementioned Incident/Accident Report revealed that at the time of Resident 4's fall, incontinence care was being provided by one nurse aide. The report stated that she turned him (the resident) away from her to provide care and he tumbled out of bed onto the floor where he hit his head. Following the fall, the report indicated that the nurse aide picked Resident 4 up from the floor put him back in bed, then transferred him to the shower bed without assistance. Review of Resident 5's clinical record revealed [DIAGNOSES REDACTED]. Quadriplegic means that all four limbs are involved). Review of the facility's Incident/Accident Report dated August 3, 2015, revealed that Resident 5 suffered a fall from a wheelchair at 4:15 p.m., on that date, and sustained a facial injury including a cut to the bridge of the nose, scratch on the chin, and a swollen center upper lip, with two teeth missing. Resident 5 was sent to the hospital for evaluation. Review of Resident 5's, Resident Care Profile revealed that at the time of the fall, Resident 5 was to have the assistance of 2 persons for transfers, bathing, and dressing. Review of facility documentation provided to the state agency on August 7, 2015, investigating the incident, revealed that Resident 5 was being transported back to her room in order to be transferred via a Hoyer lift (a device that allow a person to be lifted and transferred with a minimum of physical effort) so she could be taken to the bathroom. The report states that one nurse aide went to retrieve the mesh (sling) used with the lift, while the other unbuckled the resident's seat belt, then walked away from her, at which point Resident 5 fell forward onto the floor. In an interview with the Nursing Home Administrator on September 18, 2015 at 1:00 p.m., she confirmed that both Residents 4 and 5 were not provided with adequate supervision and assistance to prevent accidents and injuries and it is the facility's expectation that care and services are provided to residents in a manner to prevent accidents. Refer to F224 and F282. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 04/17/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 05/14/15, 04/17/14.