Every finding on record at Messiah Lifeways at Messiah Village

Based on observation, policy review, staff interviews, and review of glucometer manufacturer's guidelines, it was determined that the facility failed to provide a safe and sanitary environment that supports infection prevention and control regarding use of glucose meter (a medical device for determining the approximate concentration of glucose in the blood) disinfection for one of five nursing units. Findings include: A review of the facility policy, titled Obtaining Blood Glucose Level and Disinfecting Glucometer, last reviewed January 28, 2025, stated, use of one of the following manufacturer-approved EPA (Environmental Protection Agency)-registered disinfectant wipes or a 70% isopropyl alcohol swab to wipe down the entire surface of the glucometer. A review of the manufacturer's guidelines for the facility's brand of glucometer stated, Cleaning can be accomplished by wiping the meter down with soap and water or isopropyl alcohol but will not disinfect a meter. The manufacturer's guidelines referenced Centers for Disease Control as their resource for blood glucose monitoring safety. During an interview with Employee 1 (Registered Nurse) the Employee was asked to review her process after using the glucometer on a resident. Employee 1 stated the following, after leaving the residents room and while walking down the hall, I wipe the glucometer down with alcohol wipes. Employee 1 showed the glucometer storage bag filled with alcohol wipes. Employee 1 was asked what she does after cleaning the glucometer with alcohol wipes. Employee 1 responded, I place the glucometer back in the storage bag and in the medication cart. Employee 1 was questioned about the requirement to use a disinfectant, and she stated out loud looking at other staff, we aren't allowed to use just alcohol wipes to clean the glucometer. During an interview with the Nursing Home Administrator on August 27, 2025, at 1:45 PM, she was asked if she expected staff to disinfect the glucometer and she replied, I expect staff to follow the policy. The NHA was asked if she expects staff to follow CDC (Centers for Disease Control) guidelines for disinfection and she replied yes. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(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 two of 25 residents reviewed (Residents 2 and 3).Findings Include: Review of Resident 2's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition where the kidneys gradually lose their ability to filter waste products from the blood) and anxiety disorder (excessive fear and worry that are difficult to control and interfere with daily life).Review of Resident 2's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated June 5, 2025, revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (C. Number of falls since admission or Prior assessment - Major injury) was marked one, indicating Resident 2 had a fall with major injury during the look back period.Review of Resident 2's clinical record revealed they had a fall on May 31, 2025, that resulted with no injuries, and a fall on May 12, 2025, that resulted with a minor injury. Review of Resident 3's clinical record revealed diagnoses that included CKD and anxiety disorder.Review of Resident 3's Quarterly MDS dated [DATE], revealed section N0415. High-risk drug classes: use and indication (C. Antidepressant) is marked Yes, indicating Resident 3 was administered an antidepressant medication during the look back period. Review of Resident 3's current physician orders revealed Resident 3 was not currently receiving any antidepressant medications. Further review of Resident 3's discontinued medications revealed that Resident 3 was prescribed Sertraline 50 milligrams by mouth daily for major depressive disorder, however, that was discontinued on May 3, 2023.During an interview with the Nursing Home Administrator on August 28, 2025, at approximately 1:00 PM, it was revealed that Resident 2's fall MDS was marked in error, and was corrected, as well as Resident 3's antidepressant MDS was marked in error and was corrected; and that she would have expected them to have been completed accurately. 28 Pa. Code 211.5(f) Clinical records.28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on facility job description review, clinical record review, review of facility investigation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure a beverage was provided to residents in a form to meet the resident's individual need, which resulted in harm, evidenced by aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization for one of three residents reviewed (Resident 1). Findings Include: Review of the facility's job description for a dietary aide with an effective date of August 24, 2023, revealed Responsible for setting, servicing and cleaning the dining rooms; between meals assists with meal preparation Follows established procedures during food preparation, meal service and clean up. On September 15, 2023, Employee 3 (Dietary Aide) signed an acknowledgement of her dietary aide job description. Review of Resident 1's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness, and tremors), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). Review of Resident 1's physician orders revealed a diet order with a start date of April 11, 2024, for a carbohydrate controlled diet, mechanical soft texture, honey/moderate consistency. Review of Resident 1's meal ticket for dinner on April 11, 2024, revealed that he was to be served honey thick, diet iced tea. Review of Resident 1's nursing progress note dated April 11, 2024, revealed that Resident 1's family member came out of the Resident's room asking for a nurse to come check on Resident 1, stating that he was not acting right. The family member stated she wasn't sure if it was due to Resident 1 drinking his drink or if he was having another TIA (Transient ischemic attack - mini stroke). The family member stated that Resident 1 had taken a few sips of his iced tea and then began to cough. The family member then stated she realized that the iced tea that was on Resident 1's dinner tray was not thickened. Resident 1 became unresponsive and the family member notified the nurse. Further review of the progress note revealed that, upon nursing assessment, Resident 1 was pale with audible gurgling/wheezing and Resident 1 was unresponsive. Respirations were elevated and Resident 1 was using his accessory muscles to breath. Oxygen saturation was noted to be in the 40's (normal is 95-100%). Oxygen was applied at 5 liters via a face mask with the oxygen saturation increasing to the low 90's. Resident 1 was becoming more responsive and able to answer questions. The on-call provider was made aware and Resident 1 was transferred to the hospital for further evaluation and treatment. Review of Resident 1's hospital discharge summary dated April 15, 2024, revealed that Resident 1 was admitted to the hospital with a diagnosis of aspiration pneumonitis (inflammation of the lung due to inhalation of solids and liquids). Resident 1 was discharged from the hospital and returned to the facility on [DATE]. Review of the facility's investigation revealed a witness statement from Employee 1 (Nurse Aide) dated April 12, 2024, stating that she was told that Resident 1's family member requested a room tray for Resident 1. Employee 1 notified dining staff who prepared the tray. Employee 1 then delivered the tray while Employee 2 (Registered Nurse) was in the room with Resident 1 and his family member. Employee 1 asked the family member if she could place the tray on Resident 1's bedside table, and the family member said yes. Further review of Employee 1's statement revealed that it was Employee 3 who prepared Resident 1's dinner tray. Review of Employee 2's witness statement, revealed that Employee 1 dropped off the tray and Resident 1's family member stated she would set it up. Employee 2 confirmed that, after the incident, the iced tea on Resident 1's tray was noted to be thin liquid. The iced tea does not come pre-thickened. Dietary staff are responsible for adding a pack of thickener into the iced tea to convert the liquid to honey consistency. On April 23, 2024, at 10:43 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) provided the facility's plan of correction that was put into place as a result of the facility's investigation, which determined that Resident 1 was served the wrong texture of drink on his dinner tray. The facility's education and audits were reviewed during the survey. Starting on April 15, 2024, dining and clinical staff were educated on thickened liquids and meal tickets, ensuring that staff are double checking the liquids against the meal ticket before delivery to a resident. On April 15, 2024, audits were started on trays to ensure the correct texture of food and fluids were being served to the residents. On April 18, 2024, Employee 3 received education via a facility form titled Job Coaching Form. The form revealed that on April 11, 2024, Employee 3 was preparing room trays and a Resident who was on honey thick liquids was given a tray that had thin liquids, resulting in the Resident aspirating and being transferred to the hospital. Further review of the form revealed Employee 3 was educated that, Effective immediately, it is expected that you will serve residents the appropriate thickened liquid, either using the pre-packaged beverages, or by a thickening agent per the instructions on the pack for the appropriate level of thickness. Employee 3 signed acknowledgement of the job coaching/education on April 18, 2024. Prior to the abbreviated survey, the facility failed to provide the ordered texture of liquid to Resident 1, resulting in harm to the Resident as evidenced by aspiration pneumonitis. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. Review of facility documentation revealed that on April 19, 2024, the facility had completed education for staff and continued audits to ensure compliance. During the abbreviated survey, audits, staff education, and diet orders were reviewed. Staff interviews, Resident record review, and observations revealed no concerns with food and drink texture for the sampled residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, 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 and two of five nourishment areas. Findings include: Review of facility policy, titled 5.2 Food Storage- Sanitation and Infection Control last revised [DATE], revealed, All products are labeled and dated with a receiving date .discard outdated stock. Review of facility policy, titled Storage of Refrigerated and Frozen Foods last revised [DATE], revealed butter has a maximum refrigeration period of up to three months, and open fruit juice cartons have a maximum refrigeration period of up to seven days. Observation of the dry storage area on [DATE], at 9:50 AM, revealed two bags of red skin potatoes not dated. Observation in walk-in freezer unit on [DATE], at 9:57 AM, revealed a pan of frozen prepared food labeled Denver ham, with a use by date of [DATE]; a bag of pureed strawberries with a use by date of [DATE]; and a bag of hot dog buns not labeled or dated. Interview with Employee 1 (Food Service Director) on [DATE], at 9:58 AM, revealed he would expect items to be labeled and dated per facility policy, and discarded after use by dates. Observation of the walk-in refrigerator on [DATE], at 9:59 AM, revealed one box of tomatoes that were rotten. Observation of the three-compartment sink in the main kitchen area on [DATE], at 10:03 AM, revealed the sanitizing sink was full of water and pans. The surveyor requested Employee 1 to test the concentration (unit of measure) of the sanitizer water with the strips provided; after Employee 1 tested the sanitizer water, observation of the testing strips revealed they had an expiration date of [DATE]. Observation during initial tour of the [NAME]/Hampden pantry area refrigerator on [DATE], at 10:10 AM, revealed: eight grape juices without a date; one bag of individual margarine packets without a date; one container of salad labeled use by ,d+[DATE]; and one container of prune labeled use by ,d+[DATE]. Further observation of the [NAME]/Hampden pantry area freezer on [DATE], at 10:13 AM, revealed a container of frozen hot dogs labeled use by ,d+[DATE]. Observation during initial tour of the of the [NAME] pantry area on [DATE], at 10:19 AM, revealed a container of individual whipped butter packets on the counter with a label [DATE] to [DATE], and a container of brown sugar in the cabinet without a label or date with a spoon stored inside. Further observation during initial tour of the of the [NAME] pantry area refrigerator on [DATE], at 10:23 AM, revealed an open container of thickened apple juice with an open date of [DATE]; one container of thickened lemon water without an open date; one pan of cinnamon Danish without a label or date; half of an open pan of jelly Danish without a label or date; and one container of lemon pudding without a date. Interview with the Nursing Home Administrator on [DATE], at 2:06 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food and kitchen equipment are stored and utilized and in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and to promote dignity related to use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of one residents reviewed for catheter use (Resident 6). Findings Include: Review of facility policy, titled Foley Catheter Care effective March 1996, revealed, The collection bag should be placed below the resident, but not touching the floor, to allow for proper gravity drainage and prevent backflow of urine up the tubing and into the collection bag. Collection bag covers, also called dignity bags, are available and will be used to promote care for the resident to maintain or enhance their dignity and respect and to prevent the collection bag from dragging on the ground. Review of Resident 6's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and retention of urine. Observation on September 6, 2023, at 1:18 PM, revealed Resident 6 laying in bed with their foley catheter collection bag hanging on the side of the bed; the edge of the bag was touching the floor. Additionally, it was observed that the collection bag and the urine inside was visible from the hallway. During the observation, a visitor was present in the hallway. A later observation on that date, at 1:39 PM, revealed that the collection bag had been emptied, but was still touching the floor, and was still exposed and visible from the hallway. During an interview with Employee 2 (Nurse Aide) on September 6, 2023, at 1:43 PM, she revealed that Resident 6 used to have a dignity cover for their collection bag, but she was not sure where it went. During an interview with the Director of Nursing on September 7, 2023, at 11:08 AM, she revealed that Resident 6's catheter collection bag was replaced with one that had a built-in dignity cover. 28 Pa Code 211.12(d)(1)(5) Nursing Services

Based on observations, policy review, interviews, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two of 24 records reviewed (Residents 11 and 35). Findings include: Review of Resident 11's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 11 on September 27, 2022, at 9:07 AM, she revealed that she was concerned that a couple weeks ago a nurse aide transferred her to the bathroom using a sit-to-stand lift (mechanical device that is used to assist an individual with standing and transferring) without the use of a second person. Review of facility policy titled Lift-Sara, effective October 1994, revealed that, when using the lift, Use two people for resident and staff safety. Review of Resident 11's current care plan revealed that she was to utilize a Sara lift (sit-to-stand lift) with assist of two persons for transfers. This intervention was effective September 16, 2019. During an interview with Employee 1 (Nurse Aide) on September 28, 2022, at 12:48 PM, she confirmed that, on the date in question, she utilized a lift to transfer Resident 11 without a second person being present. She also revealed that she was aware of the need for two persons when using a lift to transfer a Resident. During an interview with the Nursing Home Administrator (NHA) on September 28, 2022, at 11:15 AM, NHA confirmed that the facility was aware of the Resident's concern, and that Employee 1 was counseled immediately following the incident. Review of Resident 35's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 35 on September 26, 2022, at approximately 11:05 AM, revealed mild [CONDITION(S)] (swelling) noted to left foot. Resident was seated in a wheelchair with feet on the floor and tubigrips (a tubular elastic bandage designed to provide tissue support and compression in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on September 27, 2022, at approximately 9:40 AM, and September 28, 2022, at approximately 12:55 PM, revealed the same aforementioned findings. Review of Resident 35's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 35's progress note revealed a note dated June 7, 2022, at 10:50 PM, that indicated that the Resident had bilateral lower extremity dependent [CONDITION(S)]; bilateral ankles and feet with purple coloring; Resident placed in bed with feet propped. Another progress note dated June 8, 2022, at 3:17 PM, indicated that the Certified Registered Nurse Practitioner (CRNP) was notified that Resident 35's wife was concerned about the Resident's dependent [CONDITION(S)]. The note further indicated that the CRNP gave no new orders at that time. A nutrition/dietary note dated July 11, 2022, at 1:14 PM, indicated the Resident had experienced a weight gain, likely due to the existence of bilateral lower extremity [CONDITION(S)] combined with excellent intakes. A nurse's note dated July 15, 2022, at 11:11 AM, indicated a new order had been obtained to apply tubigrips to bilateral lower extremities daily-apply in AM and remove in PM. A quarterly nutrition/dietary note dated August 2, 2022, at 12:41 PM, indicated the Resident had experienced a significant weight gain over the last month and over the last six months. This note indicated the weight gain was partially fluid related as the Resident has a history of dependent [CONDITION(S)] in bilateral lower extremities. Review of Resident 35's care plan revealed that the [CONDITION(S)] concern was not added to the Resident's care plan until August 3, 2022, and at that time it was added under the Resident's nutritional focus, which stated the Resident's weight gain was partially fluid related; Resident with history of dependent [CONDITION(S)] to bilateral lower extremities. A subsequent entry on the Resident's nutritional care plan, dated September 13, 2022, indicated that the Resident's bilateral lower extremity [CONDITION(S)] had improved with the compression socks. As of review date of care plan on September 29, 2022, the tubigrips were not included as an intervention on the care plan. During an interview with the NHA on September 29, 2022, at approximately 9:40 AM, the NHA was made aware of the care plan development concern, and NHA indicated she would look into it. Email communication received from the NHA on September 29, 2022, at 12:08 PM, the NHA indicated that she understood the concern that, although the [CONDITION(S)] was care planned under the Resident's nutritional focus, the intervention for the placement of the tubigrips was not added to the care plan. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of three closed resident records reviewed. (Resident 123) Findings include: Review of Resident 123's clinical record on September 16, 2021, at approximately 9:45 AM revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 123's discharge Minimum Data Set (MDS- assessment tool used to determine a resident's care and service's needs) dated for August 6, 2021, revealed under Section A Identification Information, Subsection 2100 Discharge Status was coded as 3 indicating resident was discharged to an Acute Hospital. Review of Resident 123's Discharge/Transition Plan revealed that the resident was discharged home on August 6, 2021 due to met goals. Correspondence with the Director of Nursing (DON) on September 16, 2021 at 11:25 AM, confirmed that the assessment was coded incorrectly and the resident was discharged home. 28 Pa. Code 211.5(F) Clinical Records. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on observations, meal test tray, review of select facility documents, individual resident interviews and staff interviews it was determined that the facility failed to serve food that was palatable regarding temperatures and taste for one of one test trays trialed and for two residents (Residents 113 and 153) out of 47 residents reviewed. Findings include: During an interview with Resident 113 on (MONTH) 7, 2020, at 9:54 AM, the resident stated that the food has gone downhill and the food is not always hot. During an interview with Resident 153 on (MONTH) 8, 2020, at 2:18 PM, the resident had complaints that food was cold. Review of facility provided Nursing Care Food Committee Meeting Minutes, representing nine monthly meetings going back to (MONTH) 2019, revealed concerns of foods not being served warm/hot enough for eight of the nine meeting minutes. On (MONTH) 9, 2020, a lunch meal test tray was completed of the dining service on the Donegal Nursing unit starting at 12:25 PM, following plating/service of the last resident meal, with completion of last temperature check at 12:32 PM. The test tray temperatures were taken by Assistant Dining Services Manager (ADSM) 1 using a dining services digital thermometer. Meals for residents on the Donegal unit consist of prepared bulk food items which are transported to the dining area on the unit and then placed into containers on a steam table for service, from which the desired food items are directly placed on a plate for the individual residents. Temperature results were: one serving of Bean Soup 130 degrees Fahrenheit (F)/ taste: good/ temperature: slightly warm; one serving sliced turkey with gravy 121.8 degrees F/ taste: very good/temperature: little warmth; one serving stuffing 109 degrees F/ taste: bland/temperature: no warmth; one serving diced carrots 111 degrees F/ taste: good/temperature almost cold; one serving coffee 150 degrees F/ taste: good/temperature: very good; cranberry juice 62 degrees F/ taste: acceptable/temperature: warm; pumpkin pie 46 degrees F/ taste: sweet with little pumpkin flavor/ temperature: acceptable. Review of provided Policy: 5.18 (SD) Food Temperatures; Section: Sanitation & Infection control; Policy: Food Temperature with noted last revised date of (MONTH) (YEAR), revealed A delivery standard for cold food must be served at a temperature between 33-50 F (degrees Fahrenheit) and hot food at 135 F (degrees Fahrenheit). During an interview with the Nursing Home Administrator (NHA) on (MONTH) 9, 2020, at approximately 11:45 AM, the NHA revealed the expectation that food temperatures would be palatable to residents. 28 Pa. Code 211.6(c) Dietary services. 28 Pa. Code 201.18(b)(1) Management.

Based on observations, clinical record review, and staff interviews it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of Resident 114's clinical record revealed [DIAGNOSES REDACTED]. criteria for the [DIAGNOSES REDACTED]. Review of Resident 114's Quarterly Minimum Data Set (MDS- tool used to assess resident's care and services needs) revealed the resident to be severely cognitively impaired with a score of 2 out of 15. Review of Resident 114's physician orders [REDACTED]. Review of Resident 114's Care Plan with noted last review date of (MONTH) 10, 2019, revealed a care Focus area of I have impaired ADL function related to impaired mobility, dementia and revealed an associated intervention of I utilize a Rock and Go (specialty chair designed to facilitate a rocking motion with goal to calm residents, reducing the need for protective restraints and also improves strength of leg and trunk muscles, stimulating circulation and assists with preventing sliding and pressure ulcers) to assist me with body positioning. I do not self propel. Use abductor wedge with straps between legs while in wheel chair as I will allow. Review of Resident 114's care sheet (information sheet used by nursing aides containing individualized/personalized information specific to assigned residents for care) revealed Abductor wedge between legs when up in rock & Go with straps as I will allow. Observation was made of Resident 114 in his nursing unit dining room on (MONTH) 6, 2020, at 12:02 PM seated in his wheel chair at a table. It was observed that he did not have the abductor wedge between his knees. Observation was made of Resident 114 in his nursing unit dining room on (MONTH) 8, 2020, at 12:15 PM seated in his wheel chair at a table. It was observed that he did not have the abductor wedge between his knees. At this time Nursing Aide (NA) 1 was approached in dining room, NA 1 confirmed that she was working with Resident 114 on this date. NA 1 was questioned regarding Resident 114's missing abductor wedge. NA 1 walked to resident, confirmed that he did not have it, and while heading to his nearby room made a comment regarding his room being cleaned earlier that day which she abruptly stopped. NA 1 then readily retrieved Resident 114's wedge from his room, walked immediately back to the resident and placed the wedge without any resistance from resident. Request to facility management for documentation of the abductor wedge being provided for Resident 114 was provided in the form of P[NAME] (Plan of Care) Response History. Review of Resident 114's P[NAME] (Plan of Care) Response History (documentation for the completion of specific care tasks for a resident) revealed two different sets of task sheets for him. Both sets related to Restorative Nursing: Splint checks/Monitoring BLE (bilateral (both sides) lower extremities. One of the sets specifically identified which area of the body was being monitored addressing location of Splint and also that whether for this task the Resident was Not Available, Resident Refused, or Not Applicable. Review of documentation for the dates of (MONTH) 6 and 8, 2020, revealed that Resident's BLE were being monitored and revealed no documentation to indicate that the resident was not available, not applicable or refused this care. The second set of documentation addressed Indicate the level of participation with splinting by the resident. Review of this documentation for the dates of (MONTH) 6 and 8, 2020, revealed that Resident 114 participated with encouragement on (MONTH) 6, 2020, as per charting at 11:51 AM, and on (MONTH) 8, 2020, this was not applicable as per charting at 2:59 PM The second set of documentation also addressed How did the resident tolerate ? Review of this documentation for the dates of (MONTH) 6 and 8, 2020, revealed the answer options of Well, Poorly, Resident Not Available, Resident Refused or Not applicable. Review of the documentation for the dates of (MONTH) 6 and 8, 2020, revealed that Well was checked for (MONTH) 6, 2020, as per charting at 11:52 AM and Not Applicable was checked for (MONTH) 8, 2020. Review of Resident 114's clinical progress notes failed to reveal any instances on (MONTH) 6 and 8, 2020, of resident refusing use of the abductor wedge. In summary, no observations, progress notes, or care documentation dated for (MONTH) 6 and 8, 2020, revealed Resident 114 had refused application of the abductor wedge for lunch meal time frame. During an interview with the Director of Nursing (DON) on (MONTH) 9, 2020, at approximately 12:40 PM, the DON revealed that the Nursing Aide (NA) 2 had completed the reviewed documentation incorrectly. The DON also revealed the expectation that NA 2 should have documented that the wedge was refused or the resident should have been using the wedge. The DON did not state that NA 2 had indicated the resident had refused the wedge. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on surveyor observation, manufacturer information, facility documentation, and staff interview, it was determined that the facility failed to discard expired medications for one of five medication carts observed (D hall medication cart). Findings Include: Observation of the D hall medication cart on (MONTH) 7, 2020 at 1:10 PM revealed one [MEDICATION NAME]pen with a label indicating that the medication was opened on (MONTH) 26, 2019 (42 days earlier). Review of the manufacturer's package insert for the [MEDICATION NAME]pen indicated that once the medication is open it should be stored at room temperature and discarded after 28 days even if it still has insulin left in it. Review of facility provided document regarding insulin storage states [MEDICATION NAME] should be, Refrigerate until opened, then may be stored at room temperature. Expires 28 days after first use even if some drug remains. (same for vials/cartridges/pens) Interview with the Director of Nursing on (MONTH) 9, 2020 at 11:10 AM, revealed that she would have expected the [MEDICATION NAME]pen would have been discarded after 28 days. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1)(i) Pharmacy services. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility documentation review and staff interview it was determined that the facility failed to ensure services were provided by qualified personnel for one of five personnel records reviewed (RN) 1. Findings include: Review of facility documentation revealed that on (MONTH) 22, 2019, the facility Nurse Educator 1, identified that RN 1's licensed was scheduled to expire on (MONTH) 30, 2019. Review of a written statement by Nurse Educator 1, RN 1 was emailed regarding the expiration date and asked to update and provide a copy of the renewed license on (MONTH) 22, 2019. Review of facility documentation revealed that Registered Nurse (RN) 1 did not renew the professional licensed by or on (MONTH) 30, 2019, and RN 1's professional license expired. According to the facility documentation revealed that RN 1 worked with an expired Registered Nurse license on (MONTH) 2, 6, 10, 12, 13, and 16, 2019. On (MONTH) 20, 2019, Nurse Educator 1 identified that RN 1 did not renew RN 1's professional license. The schedule was reviewed and the facility identified that RN 1 worked with an expired license. During a staff interview on (MONTH) 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that it was the facility's expectation that licensed staff have licenses while actively working at the facility. During a staff interview on (MONTH) 31, 2019 at approximately 2:15 PM, Nursing Home Administrator revealed it was the Facility's expectation that staff renew professional licenses prior to expiring. 28 Pa Code 201.18(c)(3) Management 28 Pa Code 211.12(d)(1) Nursing services

Resident #79 Hospice and End of Life 02/05/19 12:47 PM Homeland Hospice for chronic diastolic [MEDICAL CONDITION], end stage [MEDICAL CONDITION]. Admit 9/28/18. sig change 10/5/18 Quarterly MDS 12/26/18 Hospice was marked No. 02/07/19 11:05 AM meeting with NHA, DON, ADON, ADON confirmed the MDS was coded incorrectly.

Based on observations, facility policy and staff interview, it was determined that the facility failed to ensure that equipment was maintained to prevent accidents for one of six neighborhoods observed (Asper neighborhood). Findings include: Review of the facility's Medication Administration policy, last reviewed November, (YEAR), revealed that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. During an observations on the Asper neighborhood on (MONTH) 28, (YEAR), at 9:10 a.m. until approximately 9:15 a.m. revealed a medication cart which was unattended and unlocked parked in front of a resident's room. There was one housekeeping staff but no residents in the vicinity at the time. At approximately 9:15 a.m. Registered Nurse 1 (RN) 1 walked passed the medication cart and locked it. At approximately 9:17 a.m. RN 2 came out of a resident's room and acknowledged that she had left the cart unlocked when she entered the resident's room. RN 1 also acknowledged that she had locked the cart. During an interview with the Nursing Home Administrator on (MONTH) 28, (YEAR), at 2:40 p.m. she confirmed that the medication cart is to be kept closed and locked when out of sight of the medication nurse. Pa. 28 Code: 211.12(d)(1)(5) Nursing services. Pa. 28 Code 201.18(b)(1) Management

Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident has the right to be free from abuse and neglect for one of three residents reviewed (Resident 3). Findings Include: Review of Resident 3's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 3's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 3's Annual Minimum Data Set (MDS- a tool used to assess all care areas specific to the resident), dated (MONTH) 6, (YEAR), reveals in Functional Status, under Activities of Daily Living specific to eating, Resident 3 is coded as total dependence with full staff performance and 1 person physical assist. Review of an Event Review report, submitted to the Pennsylvania Department of Health, dated (MONTH) 9, (YEAR), revealed Nursing Assistant 1 (NA 1) was alleged to sit in Resident 3's room and eat her dinner while on her cell phone instead of assisting Resident 3 with his dinner meal. The review also reads Dining staff noticed for the past 3 weeks that resident's tray was coming back to the kitchen barely touched at dinner time. Also, Several witnesses state that (NA 1) eats her dinner in this resident's room when she is supposed to be feeding him . his dinner tray was being returned with hardly any food eaten but the (NA 1) documented numerous times that he had eaten 100 % and drank all fluids. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, also referred to as the PB-22, submitted by the facility, dated (MONTH) 9, (YEAR), revealed It is also reported that (NA 1) is putting 2 packets of thickener in resident's drink when he is supposed to only have one packet . Resident would not drink the fluids with 2 packs of thickener. The PB-22 also reads Nursing Supervisor spoke with resident who is able to shake his head yes or no. She asked him if he was being fed dinner regularly . he shook his head no . She asked if he was hungry and he shook his head yes. Review of a witness statement, dated (MONTH) 12, (YEAR), obtained from Dining Services Aide 1 (DSA 1), revealed NA 1 would come to her and ask for an additional packet of thickener. DSA 1 told NA 1 that his fluids are already thickened. DSA 1 reported NA 1 stated I don't care. I want another packet. DSA 1 also reported blending a brownie for Resident 3 and NA 1 allegedly responded I don't feel like giving him that . Forget it. DSA 1 went on to report Resident 3's meal percentage intake decreasing, based on her observations of his meals returning to the kitchen uneaten, but was informed by nursing staff the documentation reads Resident 3 is consuming 100 % of his meals. In response, DSA 1 reported That is 100% not true. I see those trays every evening. She is not feeding him. Review of NA 1's personnel filed revealed a letter dated (MONTH) 13, (YEAR), confirming her employment has been terminated due to substantiated allegations of neglect and false documentation. An interview with the Nursing Home Administrator (NHA) on (MONTH) 20, (YEAR), at 12:59 PM, revealed the allegations of abuse against NA 1 were substantiated based on witness statements and also documentation in the computer system regarding Resident 3's meal and fluid intakes. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review, staff interview and facility documentation, it was determined the facility failed to implement policies and procedures to prohibit and prevent resident abuse for one of three residents reviewed (Resident 2). Findings Include: Review of Resident 2's (MONTH) (YEAR), physician orders [REDACTED]. Review of an Event Report dated (MONTH) 3, (YEAR), submitted by the facility, to the Pennsylvania Department of Health, reveals in part On 10/03/18 it was reported . (Nursing Assistant- NA 1) shook . Resident 2. Further review of the Event Report revealed that according to Nursing Assistant 2 (NA 2), she (NA 2) was training NA 1 during the week of NA 1's orientation (August 26, (YEAR)-September 13, (YEAR)), when Resident 2 reportedly grabbed NA 1's hair while both staff were providing care to Resident 2. NA 1 reportedly held Resident 2's two hands and shaking . saying let go of my hair. NA 2's statement reads in part, I was in shock and report it to the nurse the next day. Additional review of the Event Report revealed NA 2 alleged she informed the Licensed Practical Nurse (LPN 1) the following day of the allegation of abuse (sometime between (MONTH) 26, (YEAR) and (MONTH) 13, (YEAR)) against NA 1, however, LPN 1 stated NA 2 told her the incident had already been reported. According to the Event Report, in regards to the allegation of abuse, LPN 1 felt it was already addressed. Review of the facility's policy and procedure manual regarding Freedom from Abuse, Neglect and Exploitation, most recently revised in (MONTH) (YEAR), reads, in part, Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator. Continued review of the policy and procedure manual revealed the definition of immediately to be considered as soon as possible . but not later than 2 hours after the allegation is made. Also, Any individual observing an incident of abuse/neglect or suspecting abuse/neglect has a responsibility and obligation to intervene immediately so that the safety of the resident can be ensured. According to Event Report, NA 1 was issued a Red Level (Severe Risk) Job Coaching followed by a 3 day suspension. NA 1 was also moved to another long term care resident Neighborhood upon her return from the suspension. An interview with the Nursing Home Administrator on (MONTH) 20, (YEAR), at 1:15 PM revealed NA 2 and LPN 1 did receive counseling and additional training on the reporting of abuse and agreed the allegation should have been immediately reported to the Nursing Home Administrator per facility policy and procedure. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (c) Nursing services

Based on observation and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for 5 residents out of 32 reviewed (Residents 23, 27, 57, 85, 131). Findings include: Surveyor observation during the lunch meal in the Asper 1 dining room on (MONTH) 26, (YEAR), at 12:20 p.m. revealed Resident 23, Resident 27, Resident 57, and Resident 85 all sitting at a table waiting to be served and assisted with lunch. At 12:29 p.m., Nursing Assistant (NA) 1 moved Residents 23, 27, 57 and 85 facing away from the table. At this time, all other residents in the dining room were eating, either independently or with assistance from staff. At 12:40 p.m., Residents 23, 27, 57, and 85 were all placed back around the table. At 12:43 p.m., Resident 27 was served lunch and was being assisted. At 12:44 p.m., Resident 23 was served lunch and was being assisted. At 12:47 p.m., both Resident 57 and Resident 85 were served lunch and were being assisted. During staff interview on (MONTH) 1, (YEAR), at 9:05 a.m. the Director of Nursing stated that the staff will move the residents away from the table and sometimes do an activity with them so they are not facing the other residents and watching them eat. Surveyor observation during this time revealed that there were no residents engaging in any activity. Review of Resident 131's clinical record revealed [DIAGNOSES REDACTED]. An observation was made on (MONTH) 28, (YEAR), at 10:30 a.m. that Resident 131's room door was wide open. Surveyor knocked on door and took two steps into Resident's room and called his name. As there was no response, surveyor backed out of room. While doing this, surveyor turned head to right and noted Resident's bathroom door, to immediate right, was wide open and that Resident was on the toilet with bottom exposed. It was observed that some staff members were in the hallway outside Resident's room. Review of Resident 131's annual Minimum Data Set assessment (MDS- assessment tool used at specific intervals to determine and plan resident care needs) dated for (MONTH) 14, (YEAR), revealed that the Resident was cognitively intact as Section C (Cognitive Status) was coded as a 15 out of 15 (coding of 15 representing highest cognitive level)and that he required staff assistance of two persons for Activities of Daily Living (ADL's) (Section G) including for bed mobility, transfers, toileting, and dressing, and in Section G0400 Functional Limitation-Range of Motion was coded as a (1)(b) to indicate impairment on one side/ lower extremity. This information thereby indicates that Resident 131 would have been assisted to the toilet with the help of two staff who had then exited the bathroom. During an interview with Director of Nursing on (MONTH) 1, (YEAR), DON revealed that Resident 131 was safe to be in bathroom by himself as capable of using call light but that would have expected the doors to be closed. 28 Pa. Code 201.29(j) Resident Rights Previously Cited 1/14/16, 12/4/15,

Based on clinical record review, staff interview, and review of resident assessment instrument completion instructions, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 32 resident records reviewed (Residents 102, 104, 132, 136, 140). Findings include: Review of Resident 102's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 102's (MONTH) (YEAR) physician orders [REDACTED]. Review or Resident 102's care plan revealed a problem with a start date of (MONTH) 19, (YEAR), I have a potential need for dental/oral care related to painful teeth, obvious cavities or broken nature teeth. Review of Resident 102's quarterly 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) revealed that section L - Oral/Dental status, L0200A through Z was not completed (all fields were blank). Email correspondence on (MONTH) 1, (YEAR), at approximately 12:20 p.m. with the Nursing Home Administrator revealed that section L of Resident 102's MDS should have been completed. Interview with the Director of Nursing (DON) on (MONTH) 1, (YEAR), at approximately 3:00 p.m. revealed that section L of Resident 102's MDS should have been completed. Review of Resident 104's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 104's annual MDS dated for (MONTH) 3, (YEAR), revealed in Section B- Hearing, Speech, Vision that in sub-sections B0200 Hearing and B0300 Hearing aids that the coding blocks were dashed out (-) representing that these two areas were not assessed. During an interview with DON on (MONTH) 1, (YEAR), at approximately 1:55 p.m. DON revealed the expectation that the coding/assessment should have been complete for Resident 104's MDS. Review of Resident 132's clinical record revealed [DIAGNOSES REDACTED]. Resident 132's record review revealed he was admitted on (MONTH) 8, (YEAR). Review of Resident 132's admission MDS dated for (MONTH) 15, (YEAR), revealed that Section K- Swallowing/Nutrition Status in Sub-section K0510- Nutrition Approaches with instruction to check all the following nutritional approaches that were performed during the last 7 days was coded as (2) while a resident and (B) Feeding tube. Review of Sub-section K0710 Percent Intake by Artificial Route revealed Resident was coded as (2)(A) indicating that while a resident, Resident 132 received 25% or less of total calories from [MEDICATION NAME] (IV nutrition) or feeding tube and was also coded as (3)(A) indicating that during the last 7 days Resident 132 had received 25% or less of total calories from [MEDICATION NAME] nutrition or feeding tube. Review of Resident 132's clinical record revealed he had not received any nutrition via [MEDICATION NAME] or tube feeding since his admission to facility on (MONTH) 8, (YEAR). During an interview with DON on (MONTH) 1, (YEAR), at 9:19 a.m. DON revealed the expectation that Resident 132's MDS should have been coded accurately. Review of Resident 136's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 136's current order summary revealed a physician's orders [REDACTED]. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, last updated (MONTH) (YEAR), revealed that the assessment is to be coded to indicate diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Review of Resident 136's (MONTH) 27, (YEAR), comprehensive 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) revealed that the assessment was coded to indicate that the resident had an active [DIAGNOSES REDACTED]. Review of Resident 136's clinical record failed to reveal a [DIAGNOSES REDACTED]. Review of Resident 136's (MONTH) 27, (YEAR), and [DATE], (YEAR), quarterly MDS's revealed that these assessments were not coded to include the [DIAGNOSES REDACTED]. An interview with the Director of Nursing on (MONTH) 1, (YEAR), at 12:05 p.m. revealed that Resident 136's is prescribed [MEDICATION NAME] for history of [MEDICAL CONDITION] and that the (MONTH) 27, (YEAR), MDS was corrected to remove the [DIAGNOSES REDACTED]. Review of the clinical record for Resident 140 revealed [DIAGNOSES REDACTED]. Review of Resident 40's comprehensive admission MDS, dated (MONTH) 16, (YEAR), revealed that section I (Active Diagnoses) was coded as having [MEDICAL CONDITION]. Further review of the active [DIAGNOSES REDACTED]. The facility was unable to provide a [DIAGNOSES REDACTED]. During an interview with the DON on (MONTH) 1, (YEAR), at 12:09 p.m., she confirmed that the facility was unable to provide a [DIAGNOSES REDACTED]. 42 CFR 483.20(g) Accuracy of Assessments. Previously cited 1/13/17, 12/4/14, 10/14/14 28 Pa. Code 211.5(f) Clinical records. Previously cited 1/13/17, 1/14/16, 12/4/14, 10/14/14 28 Pa. Code 211.12(d)(1)Nursing services. Previously cited 5/9/17, 1/13/17, 1/14/16, 12/4/14, 10/14/14 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 5/9/17, 1/13/17, 3/24/16, 1/14/16, 12/4/14, 10/14/14

Based on clinical record review and staff interview it was determined the facility failed to develop an effective discharge planning process or include the discharge plan as part of the comprehensive care plan for five of 29 resident records reviewed (Residents 15, 66, 78, 98 and 128). Review of Resident 15's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 15's clinical record revealed a social services progress note created by the Caseworker (CW 1), dated (MONTH) 28, (YEAR), that reads, in part, Resident 15 LTC (long term care) with no discharge plan. Further review of Resident 15's clinical record revealed no interdisciplinary care plan was developed to address her long-term care status. Review of Resident 66's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 66's clinical record revealed a social services progress note created by CW 1, dated (MONTH) 31, (YEAR), that reads in part, resident has LTC plan. Further review of Resident 66's clinical record revealed no interdisciplinary care plan was developed to address her long-term care status. Review of Resident 78's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 78's clinical record revealed a social services progress note created by CW 1, dated (MONTH) 31, (YEAR), that reads in part, LTC with no discharge plan. Further review of Resident 78's clinical record revealed no interdisciplinary care plan was developed to address her long-term care status. Review of Resident 98's (MONTH) (YEAR), physician orders [REDACTED]. Review of Resident 98's clinical record revealed a social services progress note created by CW 1, dated (MONTH) 8, (YEAR), that reads resident has LTC plan, Further review of Resident 98's clinical record revealed no interdisciplinary care plan was developed to address her long-term care status. Review of Resident 128's (MONTH) (YEAR), physician orders [REDACTED]. Review of Review of Resident 128's clinical record revealed a social services progress note created by CW 1, dated (MONTH) 8, (YEAR), that reads LTC with no discharge plan. Further review of Resident 128's clinical record revealed no interdisciplinary care plan was developed to address her long-term care status. An interview with the Director of Nursing on (MONTH) 1, (YEAR), revealed the facility does not create a care plan if a resident's goal is long term care. 28 Pa. Code 211.11 (d) Resident care plan

Based on clinical record review and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of 29 records reviewed (Resident 144). Findings Include: Review of the clinical record for Resident 144, revealed [DIAGNOSES REDACTED]. Resident 144 was admitted to the facility on (MONTH) 11, (YEAR) and discharged on (MONTH) 28, (YEAR). Review of the discharge plan revealed a list of medications but not a reconciliation of the pre-and post-discharge medications. During an interview with the Director of Nursing on (MONTH) 1, (YEAR), at 1:50 p.m., she stated that there should have been a pre- and post-discharge medication reconciliation. 28 Pa. Code 201.25 Discharge policy 28 Pa. Code 211.5(d)(f) Clinical records

Based on review of facility documentation, surveyor observation as well as staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests and functional abilities of one of 29 sampled residents (Resident 61). Findings include: Review of Resident 61's clinical record revealed [DIAGNOSES REDACTED]. Multiple surveyor observations on (MONTH) 26, (YEAR), between 11:45 a.m. and 2:30 p.m. revealed Resident 61 seated alone at a table near the outer wall of the dining area. The resident was not engaged in any activities, nor was she within direct view of the television in the dining area. Surveyor observation on (MONTH) 27, (YEAR), at 9:00 a.m. revealed Resident 61 seated alone at an empty table near the outer wall of the dining area. Multiple observations of this resident between 9:00 a.m. and 12:00 p.m., revealed the resident remained alone at the dining table with only a colored picture with her name on it. Surveyor observation on (MONTH) 28, (YEAR), at 11:30 a.m. again revealed Resident 61 seated alone at a table near the outer wall of the dining area. She was not engaged in any activity and was not within direct view of the television. During the times of the above observations, surveyor noted other activities to be occurring on the unit including: visitation from on-site daycare, televised gospel musical program, resident birthday party, activity department directed word game, coloring page activity, and presence of a sensory station (device which offers visual and audio stimulation via mirrors, colored fiber optic threads, bubbling water and music) in a lounge area of the unit. In addition, at least three televisions were observed to be available for public viewing. Resident 61 was not observed to be engaged in the noted activities, even as a passive participant. Additionally, no observations were made of independent activities being provided to Resident 61. Review of activities progress notes dated (MONTH) 30, (YEAR), revealed (Resident 61) enjoys the more quiet activities. She enjoys relaxing and watching TV. (Resident 61) also liked listening to music and flipping through magazines. (Resident 61 will also come to neighborhood parties. We will continue to provide (Resident 61) with things she enjoys. Review of Resident 61's current care plan revealed a concern area of I am Dependent on Staff for my Activities with a goal of I will attend 3-4 activities per week through next target date and interventions of, Advise staff of my schedule and assure that I am taken to activities, I enjoy going on bus rides, cooking, hymn sing and sometimes puzzles., as well as, Encourage me to attend activities of interest to promote cognitive stimulation and social interaction. Review of facility Recreation Detail Report (dated log of activities the resident has engaged in as well as the time spent participating in each activity) revealed that it was documented that Resident 61 was only engaged in a total of 18 activities during the months of (MONTH) and (MONTH) (YEAR), over the course of 8 days in (MONTH) and 6 days in (MONTH) for a total of 4 hours of activity participation during those months. An interview with the Director of Nursing on (MONTH) 1, (YEAR), at 12:05 p.m. revealed that no additional activity participation documentation could be located. She also revealed that the resident is careplanned for physically abusive behavior towards others, but offered no explanation as to why Resident 61 was not engaged in other independent activities. Director of Nursing further revealed the expectation that activity participation status and ability would be documented and careplanned. 28 Pa. Code 201.29(j) Resident rights.Previously cited 3/24/16, 1/14/16, 12/4/14, 6/19/14 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/24/16, 1/14/16