Every finding on record at Milton Rehabilitation and Nursing Center

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the resident representative/responsible party of changes in condition or care for three of seven residents reviewed (Resident R1, R2, and R3).Findings include: Review of the facility policy, Change in Condition dated 6/1/25, indicated, The facility shall notify the resident, his or her attending physician, and representative of changes in theresident's medical/mental condition and/or status. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 12/13/25, included diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and traumatic brain injury (a disruption in the normal function of the brain). Review of Section C: Cognitive Patterns, indicated that Resident R1 had severe cognitive impairment. Review of a progress note dated 1/3/26, at 4:11 a.m. indicated, Resident has history of emesis, usually small amounts of bile with occasional large amounts of vomit. He did experience a large emesis, projected onto his bed's privacy curtain. Further review of Resident R1's progress notes failed to reveal notification of Resident R1's resident representative / responsible party. Review of a progress note dated 1/7/26, at 9:25 p.m. indicated, CNA (nurse aide) reported to this nurse that resident had a small amount of blood in his stool. Further review of Resident R1's progress notes failed to reveal notification of Resident R1's resident representative / responsible party. Review of a progress note dated 3/5/26, at 2:30 a.m. indicated, This resident observed fully body tremors while resident was in bed x2, resident's speech was slurred, RN (registered nurse) made aware, notified MD (doctor of medicine) via communication paper. Further review of Resident R1's progress notes failed to reveal notification of Resident R1's resident representative / responsible party. Review of a progress note dated 3/15/26, at 4:31 a.m. indicated, Resident had a large brown emesis beginning of the shift, at around 0410 (4:10 a.m.) x2 more brown emesis, projectile, given Zofran (medication to treat nausea/vomiting). Further review of Resident R1's progress notes failed to reveal notification of Resident R1's resident representative / responsible party. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dysphagia (difficulty swallowing) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Section C: Cognitive Patterns indicated that Resident R2 had severe cognitive impairment. Review of a progress note dated 2/9/26, at 12:27 p.m. indicated, Resident was vomiting this AM. Medications were held. MD made aware and RN notified. Further review of Resident R2's progress notes failed to reveal notification of Resident R2's resident representative / responsible party. Review of weight change progress notes revealed:12/17/25: Five-pound loss since 11/17/25. 02/09/26: 7.7% loss. Weight loss continues and decline noted in po intake at this time. Recommend change to Enhanced diet.03/06/26: 10.4% loss. Weight loss over 6 months noted. Resident continues on enhanced diet with excellent po intakes (92%). Ice cream with am and pm snack (100% acceptance). Recommend enhanced pudding with meals. Further review of Resident R2's progress notes failed to reveal notification of Resident R2's resident representative / responsible party of continued weight loss. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated that Resident R3 had severe cognitive impairment. Review of a progress note dated 12/17/25, at 10:31 a.m. indicated Resident R3 had episodes of diarrhea. Further review of Resident R3's progress notes failed to reveal notification of Resident R3's resident representative / responsible party. Review of a progress note dated 12/17/25, at 9:57 p.m. indicated that Resident R3 had excoriation to the sacrum and groin. Further review of Resident R3's progress notes failed to reveal notification of Resident R3's resident representative / responsible party. Review of a progress note dated 12/22/25, at 1:50 p.m. indicated, Resident's stool was yellow, stringy, and has mucus with a strong odor. At 5:52 p.m. a progress note indicated a new order for liver profile lab work the next morning. Further review of Resident R3's progress notes failed to reveal notification of Resident R3's resident representative / responsible party. Review of a progress note dated 1/9/26, at 10:34 p.m. indicated that Resident R3 had continued loose stools. Further review of Resident R3's progress notes failed to reveal notification of Resident R3's resident representative / responsible party. During an interview on 3/15/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the resident representative / responsible party of changes in condition or care for three of seven residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for three of six residents reviewed (Resident 1, 2, and 3). Findings include Clinical record review for Resident 1 revealed a diagnosis list that included the following: dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells), difficulty in walking, generalized muscle weakness, unsteadiness on feet, need for assistance for personal care, muscle wasting and atrophy (decrease in size or wasting away), abnormal posture, and a cataract (a cloudy area in the lens of the eye that may impact vision). Review of the current care plan for Resident 1 revealed an activities of daily living (ADL) self-care performance deficit related to decreased physical ability, generalized weakness, blindness, and unsteadiness on feet. An intervention included, Encourage the resident to use bell to call for assistance. Further review of Resident 1's care plan revealed the resident has a potential for falls due to impaired vision, blindness, unsteadiness on feet with generalized weakness, and medication history. An intervention included to, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on the [NAME] Nursing Unit on March 28, 2025, at 11:24 AM revealed a resident could be heard yelling loudly from one of the resident rooms. The resident was heard repeatedly yelling for a urine collection device and was also heard yelling, Or you're gonna have a mess again. The resident could be heard yelling by the surveyor from two rooms away and around a corner. Further observation revealed the resident yelling was Resident 1 who was in his room on March 28, 2025, at 11:29 AM. The resident was sitting in a wheelchair near the foot of the bed and facing the unmade bed. There was a bedside table between the resident and the bed, and the resident was eating a snack at the bedside table. The resident's roommate was also present. Observation revealed the resident's call bell was at the head of the bed, which was at least six feet from the resident. Upon the surveyor entering the room and attempting to question Resident 1, an unidentified staff member arrived and assisted the resident. Further observation of Resident 1 on March 28, 2025, at 12:41 PM revealed the resident was sitting in a wheelchair at the foot of the bed and facing the bed. There was a bedside table between the resident and the bed, and staff were passing out lunch food trays. The resident's bed was now made, and the call bell was at the head of the bed and now covered up by blankets. Clinical record review for Resident 2 revealed a diagnosis list that included the following: muscle wasting and atrophy, difficulty in walking, unsteadiness on feet, and unspecified lack of coordination. Review of the current care plan for Resident 2 revealed an ADL self-care performance deficit related to generalized weakness. An intervention included, Encourage the resident to use bell to call for assistance. Further review of Resident 2's care plan revealed the resident has a potential for falls due to a history of falls, impaired mobility secondary to generalized weakness, ambulatory dysfunction (difficulty with walking), and medication history. An intervention included, Place call light and frequently used objects within reach and encourage calling for assistance if needed. Observation of Resident 2 on March 28, 2025, at 11:40 AM revealed they were lying in bed. The resident's call bell was not visible by the surveyor. A concurrent interview with Resident 2 questioning the location of the resident's call bell revealed the resident attempted to search on top and under the blankets and reach towards the side of the bed. The resident was unable to locate the call bell. Further observation of Resident 2's bed revealed the call bell was clipped to the outer perimeter of the mattress, near the top of the bed, on the resident's right side of the bed. The activator was hanging away from the bed. Further observation revealed the resident was still unable to access the call bell. Clinical record review for Resident 3 revealed a diagnosis list that included the following: dementia, repeated falls, muscle weakness, cataract, and abnormal posture. Review of the care plan for Resident 3 revealed an ADL self-care performance deficit related to inability to care for self, secondary to the dementia process, generalized weakness, and unsteadiness on feet. An intervention included, Encourage the resident to use bell to call for assistance. Further review of Resident 3's care plan revealed the resident has a potential for falls and has had actual falls due to unsteady gait and ambulating independently secondary to impaired cognition with poor safety awareness due to the dementia process. An intervention included, Place call light and frequently used objects within reach and encourage calling for assistance if needed. Observation of Resident 3 on March 28, 2025, at 11:54 AM revealed the resident was sitting in a wheelchair at the foot of the bed. An attempted interview with the resident revealed the resident did not respond to the surveyor. Observation of Resident 3's room revealed the call bell was not visible. Further observation revealed the call bell was found underneath a large stuffed animal at the head of the bed, inaccessible to Resident 3. The findings for Residents 1, 2, and 3 were reviewed in a meeting with the Nursing Home Administrator (NHA) on March 28, 2025, at 12:30 PM. The NHA further noted that Resident 3 is independent and probably placed the stuffed animal on the call bell because the resident is particular with the way things are placed in the room. However, there was no intervention in the care plan that instructed staff on the preferred placement of Resident 3's call bell. The facility failed to accommodate resident needs regarding the accessibility of call bells. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food borne illness in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on November 3, 2024, at 8:52 AM revealed the following: The right side of the food steamer was covered in dried food splatter. The flooring under the steamer and the two-door cooler and stove area beside it contained a buildup of dirt, dried food, and debris. Several potholders lying on tables and the meal service area were blackened and stained. Dust and debris were observed on the shelves where food products were stored in the dry storage area. A set of plastic risers was observed on the floor in the dry storage area with a carboard box of plastic lids and a box of food thickener sitting on it. The risers had a buildup of crumbs and debris in the crevices of the riser. A small fabric cooler lunch bag was observed inverted lying on top of the cardboard box of plastic lids with the lid hanging over the edge of the box, with liquid dripping from it, which had caused a large wet area on the plastic riser. Concurrent interview with Employee 3, cook, revealed the lunch bag is used for residents going out for dialysis and it had been washed and placed over the box to dry. Peeling paint was in multiple areas of the dry storage area on the concrete block walls behind canned products. A ceiling light cover in the dry storage room was broken/cracked. Wire shelving units in the walk-in freezer contained dust build up. A clear plastic wrapped pork loin was observed on the floor in the corner of the walk-in freezer under the shelving units. Dust buildup was observed on condenser units in the front and back walk-in coolers. A wooden shelf that extends from the steam table used for meal services was observed with corners and edges broken off exposing porous particle board material. Dishwasher temperatures to ensure optimal sanitization revealed a completed log for October 2024. Although staff had not yet washed any items in the machine on November 3, 2024, when observed, there was no evidence of any monitoring for November 1, or 2, 2024. Employee 3 obtained a new blank form from an office in the department for November 2024, and indicated staff had not placed a new form for the change to November and confirmed there was no evidence the machine temperatures were checked on November 1, or 2, 2024, when washing resident tray items and food service items occurred. The above information was reviewed with the Director of Nursing on November 4, 2024, at 2:05 PM. 483.60 (i)(2) Food store, distribute, maintain, sanitary Previously cited 12/15/23 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide dental services to meet the needs of residents for three of four residents reviewed (Residents 36, 46, and 63). Findings include: Clinical record review for Resident 63 revealed that the dentist saw them on June 14, 2023, and indicated that if Resident 63 experienced any intra-oral (inside mouth) pain or swelling, please refer to an oral surgeon for extractions as needed. On July 9, 2024, at 12:30 PM facility staff identified that they had right mandible (jaw) swelling. Resident 63 indicated a bad tooth concern. Staff visualized a molar with a large filling that was broken away from the filling and notified their physician. Resident 63's physician ordered Clindamycin (an antibiotic) 450 milligrams by mouth (PO) three times a day (TID) for one week for an infected tooth. Resident 63 saw the dentist again on July 18, 2024, who noted increased mouth pain and swelling. The dentist referred Resident 63 to an oral surgeon for x-rays and extraction of any teeth with less than favorable overall prognosis. Resident 63 saw the dentist again on September 19, 2024, who noted that the resident had not yet seen by oral surgeon. The dentist rewrote the oral surgeon referral. After extractions, will evaluate further for any necessary restorative and removable prothesis. Further review of Resident 63's clinical record revealed that the facility failed to refer the resident to an oral surgeon for follow-up as identified by the dentist on July 18, 2024, and September 19, 2024. Clinical record review for Resident 46 revealed they saw the dentist on July 18, 2024. The dentist referred Resident 46 to the oral surgeon for x-rays and extractions of any teeth with less than favorable overall prognosis. Resident 46 saw the dentist again on September 19, 2024. The dentist indicated that the resident had not yet seen the oral surgeon and re-wrote the referral to the oral surgeon. Further review of Resident 46's clinical record revealed that on October 26, 20244, at 7:22 PM they complained of a toothache. The facility notified the resident's provider. They saw Resident 46 on October 28, 2024, and ordered Orajel (for tooth pain). There was no facility documentation that Resident 46 was referred to the oral surgeon after seeing the dentist on July 18, 2024, or September 19, 2024, or after her complaint of tooth pain on October 26, 2024. The surveyor reviewed the above dental concerns during an interview with the Director of Nursing on November 6, 2024, at 10:41 AM. In an interview with Resident 36, on November 3, 2024, the resident stated she has teeth that are broken off to the gum, and the dentist in the facility told her, They should all be pulled out and a plate put in there. The resident stated she would need an oral surgeon but doesn't know how to go about getting one. A review of Resident 36's most recent dental visits revealed the resident was seen by the facility's dental service on May 22, 2024. The visit report indicated the resident was referred to an oral surgeon for extractions of all max teeth, tooth number 31, and any other teeth with a less than favorable prognosis. It was also suggested the resident use a high concentrate fluoride toothpaste such as Prevident 5000. Resident 36 was again seen by the facility dentist on September 19, 2024, in which the visit report noted the resident has not yet been seen by an oral surgeon for full radiographic examination and extractions. In an interview with Employee 6, transportation scheduler, on November 6, 2024, at 12:07 PM Employee 6 indicated Resident 36 required a medical facility oral surgeon due to having a pace maker and could not be seen in a non-medical facility based oral surgeons office and provided documentation of faxed referrals indicating attempts to schedule the resident have been unsuccessful on May 27, 2024, June 16, 2024, July 24, 2024, August 13, 2024, September, 23, 2024, and October 4, 2024. Employee 6 indicated there were no other medical facility oral surgeons to refer the resident to and the facility just finally got some other residents who were referred before Resident 36 in for an appointment. Although the facility was continuing to attempt to get the resident to the medical based oral surgeon, there was no evidence as of November 6, 2024, at 10:48 AM that the facility had implemented or addressed the suggested recommendation of the high concentrate fluoride toothpaste that was suggested back on May 22, 2024. The above information regarding Resident 36, was reviewed with the Director of Nursing on November 6, 2024, at 10:48 AM. 483.55(b) Dental services Previously cited 12/15/2023 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights for three of nine residents reviewed (Residents 22, 51, and 84) and appropriate positioning for meals for one of nine residents reviewed for nutritional concerns (Resident 105). Findings include: Clinical record review for Resident 84 revealed a diagnoses list that included severe protein-calorie malnutrition. Review of the current care plan for Resident 84 revealed the resident has a potential nutrition problem for risk of malnutrition. The goal listed in the care plan for Resident 84 included maintaining adequate nutritional status as evidenced by maintaining weight, no signs/symptoms of malnutrition, consuming at least 60 percent of meals daily, and a target date listed as November 4, 2024. Review of the most recent weights for Resident 84 were documented as: September 7, 2024: 161 pounds (lbs) October 7, 2024: 149.3 lbs (an 11.69 pound weight loss) October 8, 2024: 153 lbs A weight change note for Resident 84 on October 9, 2024, at 8:44 AM revealed a weight warning and a weight loss was noted. The recommendations from Employee 5, nutritional and dietetic technician, were a sugar free shake at lunch for nutritional support and place on weekly weights for four weeks for monitoring. Facility documentation for Resident 84 titled, Physician's Call Report, and dated October 8, 2024, noted written communication to the physician of a 12-pound weight loss in one month. New orders placed on the sheet included: weekly weights for four weeks and a sugar free shake at lunch for nutritional support. The physician noted and signed the documentation on October 10, 2024. Further review of Resident 84's clinical record revealed no evidence that the weights recommended by the dietary staff and ordered by the physician were completed. An interview regarding the weights for Resident 84 on November 6, 2024, at 11:43 AM with Employee 5 revealed that the weights were not completed. The above information for Resident 84 was reviewed with the Director of Nursing on November 6, 2024, at 12:07 PM. Clinical record review for Resident 105 revealed a diagnoses list that included muscle weakness, dysphagia oropharyngeal and oral phase (difficulty swallowing), and muscle weakness. Further clinical record review for Resident 105 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 27, 2024, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 7, which indicated cognitive impairment. The MDS also revealed that staff assessed the resident's transfer status of chair/bed-to-chair (the resident's ability to transfer to and from a bed to a chair or wheelchair) as dependent. Current physician orders for Resident 105 revealed the following orders: a diet order dated July 17, 2024, that instructed staff that the resident is to be OOB (out of bed) for all meals; an order dated July 2, 2024, that noted OOB (out of bed) for all meals every day and evening shift; and aspiration precautions (precautions taken to prevent food or fluids from entering the airway during eating) every shift for aspiration risk dated July 2, 2024. Review of the current task list for Resident 105 revealed that the resident is Dependent x2 assist with hoyer lift. Another task noted the resident is to be OOB for all meals. Review of the Treatment Administration Record (TAR) for Resident 105 for November 2024, revealed that staff were documenting the order for OOB for all meals with a check, which indicated it was completed. There were no documented refusals. Review of the Speech Therapy documentation for Resident 105 titled, Speech Therapy Recommendations, dated July 5, 2024, and July 17, 2024, revealed a recommendation on both documents that the resident be OOB for all meals. An interview with Employee 7, speech therapy, on November 5, 2024, at 12:58 PM revealed that the recommendations for Resident 105 to be out of bed during meals was to facilitate safe swallowing. Observation of Resident 105 revealed the following: November 4, 2024, at 12:25 PM: resident in bed eating lunch November 5, 2024, at 9:01 AM: resident in bed eating breakfast November 5, 2024, at 12:40 PM: resident in bed eating lunch There was no further evidence documented for Resident 105 that indicated the resident refused to be out of bed for the meals or a reason noted why the speech therapy recommendations or physician order was not followed. The above information for Resident 105 was reviewed with the Director of Nursing on November 5, 2024, at 2:18 PM. Clinical record review for Resident 22 revealed a physician's order dated March 21, 2024, for staff to complete a daily weight every morning for CHF (congestive heart failure). Staff were to notify the physician if there was a weight increase or decrease by three-pounds in a day or an increase or decrease of five-pounds in a week. Weigh Resident 22 when he gets out of bed and attempt prior to breakfast. Further review of Resident 22's clinical documentation revealed that there was no physician notification regarding their weight increase or decrease of three-pounds in a day or five-pounds in a week on the following dates: April 5, 17, and 26, 2024 May 4 and 18, 2024 June 5, 12, 22, and 28, 2024 July 3, 5, 7, 17, 30, and 31, 2024 August 7, 2024 September 18, 22, and 28, 2024 October 9, 12, 23, and 26 2024 November 2, 2024 Clinical record review for Resident 51 revealed a physician's order dated July 3, 2024, for staff to complete a daily weight every morning for CHF. Staff were to notify the physician if there was a weight increase or decrease by three-pounds in a day or an increase or decrease of five-pounds in a week. Attempt to weigh Resident 51 prior to breakfast. Further review of Resident 51's clinical documentation revealed that there was no physician notification regarding their weight increase or decrease of three-pounds in a day or five-pounds in a week on the following dates: August 5, 2024 September 21, 25, and 26, 2024 October 2, 3, 7, 8, 14, 26, 27, and 28, 2024 The surveyor reviewed the above information during an interview on November 6, 2024, at 10:41 AM with the Director of Nursing. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to properly secure and account for resident medications and biologicals on one of two nursing units (West Side Nursing Unit). Findings include: Observation on November 6, 2024, at 8:45 AM during the resident medication pass with Employee 2, licensed practical nurse, revealed a clear medication cup in the top drawer of the medication cart. The cup contained three pills: two round, brown-colored pills and a smaller pink colored one. The medication cup contained no labels, and it was unclear on the identity of the pills. A concurrent interview with Employee 2 revealed that it was unknown how long the cup of pills was in the cart because they were there when the employee started the shift. Further observation of the medication cart revealed three unsecured pills in the bottom drawer of the cart. One pill was a half of a smaller round white colored pill, another was a pink colored oblong tablet, and the third was a round white colored pill. A concurrent interview with Employee 2 revealed it was unknown how long these pills were there or the identity of the pills. Further observation of the medication cart revealed the front left, top corner of the cart was taped with multiple pieces of adhesive white colored tape. Parts of the tape were peeling away, and the peeling parts were discolored and contained small debris. An interview with Employee 2 revealed it was unknown how long the tape was on the cart or how the taped area was cleaned or sanitized. The above information was reviewed with the Director of Nursing on November 6, 2024, at 10:35 AM. 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 201.18(b)(1) Management 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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood/behavior (Resident 25). Findings include: Clinical record review revealed the facility admitted Resident 25 on August 24, 2024, with a diagnosis of chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). A review of Resident 25's plan of care revealed a care plan was added addressing Resident 25's history of trauma until September 24, 2024, one month after the resident's admission, and only indicated the resident had the potential for ineffective coping related to stress from a traumatic event of complications during childbirth. Further review of Resident 25's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization. The Director of Nursing was made aware on November 4, 2024, at 2:00 PM that Resident 25's plan of care failed to indicate potential triggers for Resident 25's trauma and how staff can prevent re-occurrence. A social service note dated November 5, 2024, at 4:05 PM revealed the social worker had met with Resident 25 to review triggers of the resident's trauma, which included seeing and speaking about very small children or babies had the ability to create increased frustration and sadness. Resident 25's plan of care was revised on November 4th and 5th, 2024, with events that trigger the resident's trauma and individualized interventions to prevent re-occurrence of the trauma, after it was brought to the facility staff's attention. 483.25(m) Trauma informed care Previously cited 12/15/24 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing support for a resident requiring staff assistance for one of two residents sampled for activities of daily living (Resident 57). Findings include: Interview with Resident 57 on November 3, 2024, at 11:50 AM revealed that the facility admitted him on August 29, 2024. Resident 57 stated that he did not get a shower for his first month in the facility. Clinical record review for Resident 57 revealed his admission MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated September 5, 2024, noted staff assessed him as requiring partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for bathing. Further review of Resident 57's clinical record revealed diagnoses including spina bifida and paraplegia. Clinical record for Resident 57 revealed his preference for bathing is to receive a shower on Mondays and Thursdays. Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) revealed Resident 57 did not receive a shower from August 29 to October 6, 2024. There were no documented refusals. The facility failed to provide assistance for bathing for a Resident 57 dependent on staff assistance. These findings were reviewed during a meeting with the Director of Nursing on November 5, 2024, at 2:39 PM and she confirmed there was no further documentation that Resident 57 received showers per his preference. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for four of 24 residents reviewed (Residents 63, 84, 113, and 115). Findings include: Clinical record review for Resident 84 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated August 26, 2024, in which facility staff assessed the resident as receiving insulin during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 84 received insulin during the assessment period for the MDS noted above. An interview with Employee 4, registered nurse assessment coordinator, on November 5, 2024, at 9:44 AM confirmed that Resident 84 did not receive insulin as indicated during the assessment period. Clinical record review for Resident 63 revealed that on July 9, 2024, at 12:30 PM facility staff identified that they had right mandible (jaw) swelling, with Resident 63 indicating a bad tooth concern. Staff visualized a molar with a large filling that broken away from the filling and notified their physician. Facility staff completed Resident 63's annual MDS on August 4, 2024, which indicated that the resident did not have any obvious or likely cavity or broken natural teeth. Closed clinical record review for Resident 115 revealed that the facility completed a discharge MDS on August 12, 2024, which indicated that the resident was discharged to an acute care hospital. Review of Resident 115's clinical record revealed social service documentation dated August 12, 2024, at 2:36 PM that they discharged to home with family. The surveyor reviewed the above findings during an interview with the Director of Nursing on November 5, 2024, at 2:33 PM and November 6, 2024, at 10:41 AM. Clinical record review for Resident 113 revealed a significant change MDS dated [DATE], in which facility staff assessed Resident 113 as receiving insulin during the assessment period. Further clinical record review revealed no evidence that Resident 113 received insulin during the assessment period for the MDS noted above. Interview with Employee 4 on November 5, 2024, at 9:46 AM confirmed Resident 113 did not receive insulin as indicted during the assessment period. 483.20(g) Accuracy of Assessments Previously cited 12/15/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (West Side Nursing Unit). Findings include: Observation on November 6, 2024, at 9:00 AM of the [NAME] Side Nursing Unit revealed the following: A white air unit on the ceiling in the resident hallway adjacent to the nurse's station had a significant build-up of a black-colored substance on the interior vents. Observation on November 6, 2024, at 9:15 AM of the [NAME] Side Nursing Unit shower room revealed the following: A resident lift in the shower room had a significant accumulation of debris on the standing pad of the unit. The canvas storage bag attached to the lift had an extensive build-up of debris in the bag that included the following: two large pill-like objects that were partially dissolved, an open and unrolled elastic bandage, an exam glove, a crushed plastic disposable cup, and various other unidentified dirt and debris in the bottom of the canvas bag. The resident shower stall contained black colored dot-like stains on the perimeter wall of the shower cove base where the wall met the floor. There were multiple dead winged insects on the exterior of the light in the shower stall. The shower curtain contained multiple black colored stains of various sizes on the interior/exterior of the shower curtain especially near the bottom of it. Employee 1, nurse aide, was advised of the findings for the [NAME] Side Nursing Unit shower room on November 6, 2024, at 9:20 AM and proceeded to start cleaning out the canvas storage bag. The above information was reviewed with the Director of Nursing on November 6, 2024, at 10:35 AM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on observation and resident and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 24 residents sampled (Resident 57). Findings include: Observation on November 3, 2024, at 10:19 AM revealed Resident 57 was wheeling himself down the hallway with his uncovered catheter bag hanging full of urine under his wheelchair. Observation on November 3, 2024, at 11:52 AM revealed Resident 57 was participating in an activity in the activity room with his uncovered catheter bag hanging full of urine under his wheelchair. Observation on November 3, 2024, at 2:03 PM revealed Resident 57 was in the hallway outside of his room with his uncovered catheter bag full of urine under his wheelchair. Interview with Resident 57 on November 5, 2024, at 10:54 AM confirmed the facility placed the catheter bag covering on November 4, 2024, after the surveyor's discussion with Resident 57. The surveyor reviewed the above findings during a meeting with the Director of Nursing on November 5, 2024, at 2:35 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen and one of two nursing units (East Nursing Unit). Findings include: Observation of the facility's kitchen on [DATE], at 10:11 AM revealed Employees 3 and 4, dietary aides, were utilizing the dishwasher to clean breakfast dishes. Concurrent observation of the dishwasher gauges revealed that the wash temperature was 110 degrees Fahrenheit, and the final rinse temperature was 142 degrees Fahrenheit. There was no sanitizing agent connected to the dishwasher. Employee 5, dietary manager, acknowledged the low wash and rinse temperatures on the dishwasher and began cleaning out the three-tiered sink to hand wash dishes. She indicated that the concern was identified that morning and a contractor was onsite to fix the hot water boiler currently. Employees 3 and 4 did not identify the low water temperatures and that the facility's dishes were not being sanitized by high temperatures prior to being identified by the surveyor. Review of the dishwasher's temperature log dated [DATE] revealed the standard dishwasher wash temperatures should be between 140 and 160 degrees Fahrenheit and the rinse temperatures should be between ,d+[DATE] degrees Fahrenheit. Staff were to notify the supervisor if not within standard. Review of the [DATE], dishwasher temperatures for breakfast revealed that the wash temperature was 165 degrees Fahrenheit, and the rinse temperature was 150 degrees Fahrenheit. Interview with Employee 5 on [DATE], at 10:44 AM revealed that she was not aware of these temperatures prior to staff washing dishes and acknowledged that staff should not have utilized the dishwasher that morning. Interview with Employee 6, maintenance, on [DATE], at 1:58 PM revealed that a concern was identified with the facility's boiler that supplies the kitchen on [DATE], with a contractor fixing the concern. Employee 6 again noted issues when he arrived on-site [DATE], at 6:00 AM and again notified the contractor, with them arriving at the facility shortly thereafter. Employee 6 revealed that the contractor had again fixed the concern and that the boiler was back online. He also noted that there was a hot water booster for the dishwasher to meet the hot water sanitizing requirements. The facility's dishwasher temperatures did not meet temperatures to properly sanitize the facility's dishes. This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on [DATE], at 2:30 PM. Observation of the East Side Nursing Unit nutrition closet on [DATE], at 1:30 PM revealed the following: a cupboard door under the sink had brown colored stains dried on the inside of the door wooden shelves in the overhead cupboards had debris and grime on the shelves and the wood appeared to be coming off on some areas of the shelving there was a can of expired fruit with a best by date of [DATE], in the cupboard a pink wash basin with brown colored dried stains on the inside of it was located on the top of the refrigerator and had a hard oatmeal creme pie in it the bottom grates below the refrigerator door had a significant build-up of a brown colored and dried substance there were multiple snacks that had fallen on the ground and were accumulating behind the refrigerator there was a coffee ground-like substance in a plastic zip bag with no label or use by date located in one of the cupboards The Nursing Home Administrator and Director of Nursing were notified on [DATE], at 1:30 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 17 and 52). Findings include: The facility's medication error rate was 15.15 percent based on 33 medication opportunities with two medication errors. The facility policy entitled, Administering Medications, last reviewed without changes on October 13, 2023, revealed that medications must be administered in accordance with physician orders. The individual administering the medication must check the label to verify the right medication, right dosage, right time, and the right method of administration before giving the medication. Observation of a medication administration pass on December 12, 2023, at 8:42 AM revealed Employee 1, licensed practical nurse, preparing to administer Spiriva (treats breathing disorders) one capsule to inhale orally, Fenofibrate (treats high cholesterol) 145 mg (milligrams), Raloxifene (treats osteoporosis) 60 mg, and Ditropan XL (treats overactive bladder) 5 mg to Resident 52. Employee 1 handed the Spiriva inhaler to Resident 52, and instructed her to take a deep breath in. Employee 1 took back the Spiriva inhaler after Resident 52 inhaled on the medication one time. Review of the manufacture's guidelines for Spiriva, revised November 2021, indicated that two inhalations are to be completed for the same capsule, to ensure that the full medication dose is delivered each day. Employee 1 did not provide further education or prompting to Resident 52 to complete a second inhalation of the Spiriva capsule. Employee 1 crushed the Fenofibrate, Raloxifene, and Ditropan XL and mixed them with pudding prior to administering them to Resident 52. Review of the Fenofibrate and Ditropan medication cards (a blister pack of the medication sent by pharmacy) revealed a sticker indicating that the medications should not be crushed. Review of the facility pharmacy's do not crush list, copyrighted in 2020, indicates that Raloxifene should not be crushed. Interview with Employee 1 on December 12, 2023, at 10:26 AM confirmed the above findings for Resident 52. Interview with the Administrator and Director of Nursing on December 13, 2023, at 2:00 PM acknowledged the above findings regarding Resident 52's medication errors. Observation of a medication administration pass on December 12, 2023, at 9:18 AM revealed that Employee 2, licensed practical nurse, administered Fluticasone Propionate 50 mcg (micrograms) per spray two sprays per nostril to Resident 17. Clinical record review for Resident 17 revealed a current physician's order for Fluticasone Furoate 27.5 mcg per spray two sprays in both nostrils daily for allergies. Interview with Employee 2 on December 12, 2023, at 10:09 AM confirmed that she administered Fluticasone Propionate 50 mcg per spray not Fluticasone Furoate 27.5 mcg per spray as ordered to Resident 17. Employee 2 acknowledged that she administered the incorrect medication and incorrect dosage of the medication to Resident 17. The surveyor reviewed the above information during an interview on December 12, 2023, at 1:18 PM with the Director of Nursing and on December 13, 2023, at 2:41 PM with the Nursing Home Administrator. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for five of five residents reviewed (Residents 6, 25, 29, 44, and 69). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip-lock bag. Clinical record review for Resident 44 revealed a current physician's order for staff to administer Albuterol Sulfate nebulizer solution 0.083% one vial inhale orally via nebulizer every 6 hours as needed for wheezing or shortness of breath. Observation of Resident 44's bedside stand on December 12, 2023, at 11:23 AM and December 13, 2023, at 10:22 AM revealed that there was a nebulizer machine with nebulizer tubing, cannister, and mouthpiece connected. The canister and mouthpiece were unbagged and lying directly on the resident's bedside stand. The surveyor reviewed the above information during with the Director of Nursing and the Nursing Home Administrator on June 15, 2023, at 2:30 PM. Clinical record review for Resident 25 revealed a physician's order dated July 4, 2023, for staff to administer Resident 25 oxygen at two liters per minute via the nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) continuously. Observation of Resident 25's Room on December 12, 2023, at 10:34 AM revealed Resident 25 was out of the room and her oxygen tubing was hanging on the overbed table unbagged, with the nasal cannula piece directly touching the floor. The surveyor reviewed the above information for Resident 25 with the Director of Nursing and the Nursing Home Administrator in a meeting on December 14, 2023, at 2:18 PM. Clinical record review for Resident 29 revealed a current physician's order dated November 17, 2023, that indicated the resident was to wear BiPAP (Bi-level positive airway pressure; a mask worn during sleep that helps to keep the airways open) every night with oxygen at two liters per minute. Observation of Resident 29's BiPAP on December 13, 2023, at 9:43 AM and 12:48 PM and again on December 14, 2023, at 12:38 PM revealed the resident was awake and sitting upright in bed. The resident's BiPAP mask was draped over the resident's BiPAP machine located on a dresser next to the bed. The mask was not bagged or protected from contamination from the ambient environment during any of these observations. Clinical record review for Resident 69 revealed a current physician's order dated September 5, 2023, that indicated the resident was to wear supplementary oxygen via nasal cannula continuously at four liters per minute. Nursing documentation for Resident 69 dated December 9, 2023, at 11:43 PM revealed the resident was sent to the hospital. Further documentation dated December 10, 2023, at 9:00 AM revealed the resident was admitted to the hospital. Observation of Resident 69's bedroom on December 13, 2023, at 9:45 AM and again on December 14, 2023, at 12:38 PM revealed a nebulizer mask on the bedside table. The mask was not bagged or protected from contamination from the ambient environment. Clinical record review for Resident 6 revealed a current physician's order dated November 28, 2023, that indicated the resident was to receive ipratropium-albuterol inhalation solution (a combination of medication that helps to reduce inflammation in the airways and increase airflow to the lungs) 0.5 - 2.5 milligrams in 3 milliliters and inhale orally via nebulizer every six hours as needed for wheezing and shortness of breath. Observation of Resident 6's room on December 14, 2023, at 12:30 PM revealed that there was a nebulizer mask hanging from the nebulizer machine on a dresser next to the bed. The mask was not bagged or protected from contamination from the ambient environment. The above findings for Residents 6, 29, and 69 were again noted on December 14, 2023, at 1:45 PM during a walk through with the Nursing Home Administrator who reported the oxygen equipment should be bagged. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited 1/10/23 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, comfortable, home-like environment on two of two nursing units (East Nursing Unit and [NAME] Nursing Unit; Residents 4, 7, 25, 52, 99, and 110). Findings include: Observation of a storage room with various respiratory equipment and tube feedings with the title Coat Rack on the door located on the East Side Nursing Unit on December 13, 2023, at 12:54 PM revealed: a green lidded bowl on top of a water heater that held contents, which were covered in a white, fuzzy, mold-like substance, a large plastic fountain drink cup with a straw in the lid discarded under the rack that held tube feedings, a balled-up surgical mask on a shelf holding respiratory supplies, and half a 12-ounce can of soda on a shelf next to exam gloves. These findings were reviewed with Employee 10, a licensed practical nurse, on December 13, 2023, at 1:10 PM. Observation of a shower/bathroom located next to the nutrition room on the East Nursing Unit on December 13, 2023, at 1:14 PM revealed the following: a strong offensive odor noted upon entering the room, black spots covering the caulk in the corners of a shower stall, a hole in the wall along the lower border of a temperature gauge located above the shower control handle, a handrail near the sink was loose and starting to detach from the wall, a piece of protective wall covering under the handrail was broken and jagged. Observation of a shower/bathroom on the East Side Nursing Unit on December 14, 2023, at 1:27 PM revealed a wooden shelf located in a shower stall that had two Exelon transdermal patches stuck to the top of it and a large protective wall covering was starting to detach from the wall near the ceiling. Observation of Resident 110's room on December 13, 2023, at 1:00 PM revealed an accumulation of debris (including a plastic spoon, paper debris, crumbs, and a baked goldfish snack) and grime on the floor. The resident's bed sheet was covered in crumbs and stained especially near the foot of the bed. The above information for the East Side Nursing Unit shower and bathroom, storage closet, and Resident 110's room was reviewed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:57 PM. Observation of the East Nursing Unit on December 12, 2023, at 11:31 AM, December 13, 2023, at 10:23 AM, and December 14, 2023, at 2:51 PM revealed that Resident 4's room had a very strong urine smell. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 3:00 PM. Observation of the [NAME] Nursing Unit on December 12, 2023, at 10:34 AM revealed the following: Resident 25's floor in her room was dirty with brown spillage spots, trash, and food on the floor. Resident 99's floor was dirty between Bed A and the wall, there were multiple areas on the floor with dried food and spillage spots. Residents 7 and 52's floor was extremely dirty, with multiple spillage spots, dried food, and trash on the floor. 28 Pa. Code 201.18(b)(3) Management

Based on review of employee personnel records, select facility policy review, and staff interview, it was determined that the facility failed to adequately implement its established abuse prohibition policy for two of five employees reviewed (Employees 7 and 8). Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees. The policy entitled Abuse last reviewed October 13, 2023, indicates that a criminal background check will be conducted on all prospective employees. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation. The policy entitled Pre-Employment Criminal Background Screening last reviewed on July 5, 2023, indicates that continued employment depends on successful completion of the criminal background check. If the results of the check are unfavorable, any offer of employment shall be withdrawn; or, if the employee has started working before the results of the check are available, employment may be terminated. The facility cannot employ anyone who has been found guilty by a court of law abusing, neglecting, or mistreating nursing facility residents. Review of Employee 7's, receptionist, personnel record revealed that the facility hired her on August 2, 2023. There was no documented evidence in Employee 7's personnel file to indicate the facility obtained a criminal history background report until December 14, 2023, when the surveyor brought it to the attention of administration. Review of Employee 8's, dietary aide, personnel record revealed that the facility hired him on October 4, 2023. There was no documented evidence in Employee 8's personnel file to indicate the facility obtained a criminal history background report until December 14, 2023, when the surveyor brought it to the attention of administration. Interview with Employee 9, human resources director, on December 14, 2023, at 11:08 AM, confirmed the above findings. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected resident status for two of 23 residents reviewed (Residents 12 and 58). Findings include: Clinical record review for Resident 58 revealed the resident was admitted to the facility on [DATE]. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) for Resident 58 dated September 24, 2023, noted the facility staff assessed the resident as receiving an anticoagulant six days in the assessment period. Further clinical record review revealed no evidence that Resident 58 received an anticoagulant during the assessment period for the MDS noted above. An interview with Employee 11, the Registered Nurse Assessment Coordinator, on December 14, 2023, at 11:09 AM confirmed that Resident 58 did not receive an anticoagulant. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:57 PM. Clinical record review for Resident 12 revealed that the facility completed an annual MDS assessment on November 27, 2023, which indicated that the resident was not on dialysis. Review of Resident 12's clinical record revealed a physician's order dated November 15, 2023, and a care plan dated August 4, 2022, for her to attend dialysis on Monday, Wednesday, and Friday. The surveyor reviewed the above MDS discrepancy for Resident 12 during an interview with the Nursing Home Administrator and Director of Nursing on December 13, 2023, at 2:42 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 18). Findings include: Clinical record review for Resident 18 revealed a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission on October 1, 2020. During an interview with Resident 18 related to her diagnosis of PTSD on December 12, 2023, at 10:47 AM revealed that she did not want to discuss her triggers, she stated that she has talked to a professional about it. A review of Resident 18's most recent quarterly minimum data set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment, dated September 1, 2023, indicated PTSD was an active diagnosis for Resident 18. Further review of Resident 18's current care plan revealed an identified behavioral-emotional problem indicating Resident 18 has a psychosocial well-being problem related to a diagnosis of PTSD and anxiety. There were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring). Clinical record review of Resident 18's current care plan revealed an identified problem of trauma-informed care related to PTSD, with no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it were reoccurring). Resident 18 saw a nurse practitioner with psychological services six times in the last year with the PTSD diagnosis listed with no treatment plan or triggers noted. Further review of Resident 18's clinical record revealed documentation by a licensed clinical social worker on October 19, 2023, noting that the diagnosis of PTSD is related to neglect, verbal, and emotional abuse by Resident 18's ex-husband/caretaker. An interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:20 PM confirmed these findings. The facility failed to identify and care plan triggers that may retraumatize Resident 18 related to her diagnosis of PTSD. 28 Pa Code 211.12 (a)(d)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of three resident reviewed (Resident 83). Findings include: The facility policy entitled, Administering Pain Medications, last reviewed without changes on October 13, 2023, revealed that the facility will assess a resident's level of pain prior to administering non-narcotic or narcotic analgesics. Staff will follow the medication administration per the physician's order and utilize standardized pain assessment tools including the 10-point pain intensity scale. The facility policy did not identify what mild, moderate, and/or severe pain was per the 10-point pain intensity scale. Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 83 revealed physician's orders for the following pain medications: Ordered on August 16, 2023, Acetaminophen (for mild pain) 500 milligrams (mg) 1 tablet by mouth (PO) every 6 hours as needed (PRN) for pain. Ordered on September 21, 2023, Morphine (for severe pain) 100 mg/5 ml (milliliters) 0.25 ml PO every 4 hours PRN for pain/shortness of breath. There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters or that the facility identified that multiple medications were available for the same pain parameter. Review of Resident 83's September, October, November, and December 2023 MAR (medication administration record, a form to document medication administration) revealed that staff administered the following PRN pain medications: Acetaminophen 500 mg 1 tablet PO every 6 hours PRN for pain September 22, 2023, at 9:11 PM for a pain level of 6. September 23, 2023, at 3:34 AM for a pain level of 4. October 4, 2023, at 3:35 PM for a pain level of 7. October 5, 2023, at 3:21 PM for a pain level of 7. October 6, 2023, at 12:23 PM for a pain level of 5. October 15, 2023, at 1:00 PM for a pain level of 7. October 19, 2023, at 11:28 AM for a pain level of 5. October 19, 2023, at 7:43 PM for a pain level of 7. October 20, 2023, at 1:55 AM for a pain level of 5. October 30, 2023, at 3:47 AM for a pain level of 5. November 21, 2023, at 5:44 AM for a pain level of 5. November 23, 2023, at 7:17 PM for a pain level of 7. November 26, 2023, at 3:21 PM for a pain level of 7. November 29, 2023, at 5:18 PM for a pain level of 7. December 3, 2023, at 6:30 PM for a pain level of 4. December 10, 2023, at 8:32 PM for a pain level of 6. December 12, 2023, at 8:23 PM for a pain level of 5. Morphine 100 mg/5 ml 0.25 ml PO every 4 hours PRN for pain/shortness of breath November 5, 2023, at 10:28 AM for a pain level of 6. November 8, 2023, at 11:30 AM for a pain level of 5. December 7, 2023, at 6:43 PM for a pain level of 6. December 8, 2023, at 7:35 PM for a pain level of N/A (not applicable). The surveyor reviewed Resident 83's pain information during an interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:18 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of select facility policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain an acceptable parameter of nutritional status for one of six residents reviewed for nutrition concerns (Resident 58). Findings include: The policy entitled Weight Assessment and Intervention Policy, last reviewed without changes on October 13, 2023, revealed that, Any weight change of greater than or less than five pounds within 30 days will be retaken for confirmation. A significant weight change is defined as: more or less than five percent within 30 days, and more or less than 10 percent within six months. The policy further noted that if the weight loss meets the definition of significant then the dietitian should discuss with the interdisciplinary team and make recommendations. The policy noted the dietitian will also review the monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether the definition of significant weight change is met. Review of Resident 58's current care plan revealed the resident has a nutritional problem or potential nutritional problem and inadequate intake related to impaired vision. Some interventions included: monitor, record, and report to the physician as needed signs and symptoms of malnutrition: emaciation (cachexia - being abnormally thin or weak), muscle wasting, and significant weight loss of three pounds in one week, greater than five percent in one month, greater than 7.5 percent in three months, or greater than 10 percent in six months; weigh per physician orders and notify the physician, responsible party, and dietitian of any significant changes. Clinical record review for Resident 58 revealed assessments of the weights as follows: November 1, 2023, 174.6 pounds November 8, 2023, 175.2 pounds November 15, 2023, 175.0 pounds December 1, 2023, 156.2 pounds Resident 58 experienced an 18.4 pound significant weight loss of 10.5 percent in 30 days, from November 1, 2023, to December 1, 2023. There was no evidence that Resident 58's 30-day weight loss from November 1, 2023, to December 1, 2023, was addressed by the registered dietitian or physician as of December 13, 2023, nor any evidence Resident 58's registered dietitian or physician was made aware of Resident 58's weight loss as of December 13, 2023. There was also no evidence that Resident 58 was reweighed to ensure accuracy of the weight obtained on December 1, 2023. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 13, 2023, at 2:30 PM. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and family and staff interview, it was determined that the facility failed to provide physician ordered interventions and timely assessments/interventions from a qualified nutrition professional for residents to promote acceptable parameters of nutritional status resulting in harm for one of seven residents reviewed for nutrition concerns (Resident 21). The facility also failed to weigh a resident per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: An observation of Resident 21 on January 18, 2022, at 12:55 PM revealed the resident lying in bed, as a staff member placed a lunch tray in the resident's room on a tray table located at the bottom of the resident's bed and then walked out of the room. It was not until 1:10 PM when another staff member walked by the room and noticed the lunch tray was out of Resident 21's reach and proceeded to enter the room and set the resident up for lunch and then left the room. The resident was observed slowly taking a few bites of the food. In an interview with Resident 21's family member on January 19, 2022, at 10:40 AM the family member stated the resident had been receiving nutrition by a tube, but was eating now, and no longer needed the tube. A follow up observation of Resident 21 on January 20, 2022, at 12:40 PM revealed the resident was sitting up in bed with a lunch tray in front of her, slowly taking a few bites of the food. No staff was present with the resident. Clinical record review for Resident 21 revealed the resident was assessed by facility staff on November 5, 2021, in a significant change MDS (Minimum Data Set, an assessment completed at periodic intervals of time to assess resident care needs) as requiring extensive assistance of one-person physical assistance for feeding. Resident 21 BIMS (Brief Interview for Mental Status, determines a residents cognition) was unable to be assessed due to her cognitive impairment. Resident 21 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 21's meal intake consumption record, and MAR's for October, November, and December 2021, and to date for January 2022, revealed the following: October 2021 (30 meal periods): 11 meals without any meal intake recorded 5 meals with less than 50 percent intake recorded 5 meals 51 to 75 percent intake recorded A review of the October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . November 2021: 32 meals without any meal intake recorded 22 meals with less than 50 percent intake recorded 6 meals 51 to 75 percent intake recorded Review of Resident 21's November 2021, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . December 2021: 32 meals without any meal intake recorded 29 less than 50 percent intake recorded 2 meals 51 to 75 percent intake recorded Review of Resident 21's December 2021, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . January 1-20, 2022 (60 meal periods): 31 meals without any meal intake recorded 12 less than 50 percent intake recorded 2 meals 51 to 75 percent intake recorded Review of Resident 21's January 2022 MAR from January 1-20, 2022, revealed no evidence the resident was administered any bolus tube feeding during the month, as ordered based on the meal consumption. A review of Resident 21's weight record revealed the resident was being weighed monthly. Resident 21 weighed 222.2 pounds on October 7, 2021, prior to the tube feeding order change on October 20, 2021. Resident 21 was not weighed again until November 7, 2021, weighing 208.8 pounds, a 13.4 pound (6 percent severe weight loss in one month). A nutrition note dated November 4, 2021, indicated the resident's weight was not available yet for the month, that the resident had been changed to bolus tube feedings based on her intakes, and the resident had not required a bolus feeding yet, despite the intake review noted above. No new interventions were added. There was no evidence of any further nutrition documentation until November 26, 2021, when it was noted Resident 21 had a significant weight loss based on the November 7, 2021, weight. It was noted the loss may be due to switching to bolus tube feedings based on the resident's intake. There was no evidence the absence of meal intake consumption even being recorded, or that a bolus feeding was not administered on the multiple opportunities the meal intake fell below the threshold was addressed. No new interventions were added. Resident 21 was not weighed again until December 7, 2021. Resident 21 now weighed 199.4 pounds, an additional 9.4 pound loss (4.5 percent) since the November weight of 208.8 pounds, and a loss of 22.8 pounds (10.2 percent) since October 2021, prior to the change in bolus feedings. As on January 20, 2022, there was no evidence of any further nutrition documentation or notes addressing the continued weight loss, absence of meal intake consumption percentages, or not administering the bolus feeding as ordered for Resident 21 since the November 26, 2021, note. Resident 21 did not get weighed again until January 7, 2022, at 203.2 pounds, showing a slight increase of 3.8 pounds, but remained a severe weight loss of 19 pounds (8.5 percent) in 90 days. A follow up interview conducted with Employee 8, diet technician, on January 23, 2022, at 11:53 AM confirmed there were no further nutrition notes since November 26, 2021, for Resident 21, and she was not aware the resident had weight loss, or that the resident was not receiving the bolus tube feeding as ordered even though the resident had intakes below 75 percent. The findings for Resident 21 were reviewed with the Nursing Home Administrator and Director of Nursing on January 23, 2022, at 11:00 AM. Review of Resident 100's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 100's daily weights revealed that nursing staff weighed Resident 100 on November 16, 2021, at 243 pounds. Nursing staff did not weigh Resident 100 again until December 13, 2021, when she weighed 189.6 pounds, a 21 percent weight loss in one month. There was no documented evidence to indicate why Resident 100's daily weights were not completed, no documented evidence to indicate Resident 100's physician was notified, nor was there documented evidence to indicate that a nutritional assessment was completed by the facility's dietician after the severe weight change was noted. Interview with Employee 8, on January 21, 2021, at 9:55 AM confirmed the above findings for Resident 100. 483.25 (g)(1)(2) Assist and maintain nutrition parameters Previously cited 12/4/2020 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, review of select facility policies, and resident and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm related to a sustained fracture on one of two nursing units (West, Resident 93). Findings include: The facility policy entitled, Abuse Prevention and Reporting, last reviewed by the facility without changes on (MONTH) 16, (YEAR), revealed that it is the policy of the facility to institute an abuse prevention program, which includes the prevention of physical neglect. The policy definition of physical neglect is indicated as not following a resident's plan of care to safely position a dependent person. An observation of Resident 93 on (MONTH) 17, (YEAR), revealed the resident had a cast on her right lower leg. In a concurrent interview with Resident 93, she indicated someone fell on her leg, and broke it. The resident also indicated that because of the broken leg, she must use a bed pan now instead of the toilet, because she now needs to be transferred with a Hoyer lift (a mechanical device used to assist in resident transfer), and it does not fit in her bathroom. The clinical record review for Resident 93 revealed a Minimum Data Set assessment (MDS, an assessment tool utilized to determine resident care needs) dated (MONTH) 10, (YEAR), that assessed Resident 93 as a BIMS (Brief Interview of Mental Status), score of 14, which indicated the resident was cognitively intact, and that the resident required extensive assistance of two plus persons physical assist for transfers. Resident 93's plan of care revealed interventions for activities of daily living self-care performance dated (MONTH) 27, (YEAR), that indicated the resident was to receive maximum assistance of two with a recommended forward approach bear hug with a gait belt for transfers. The clinical record review for Resident 93 revealed a physical therapy evaluation dated (MONTH) 26, (YEAR), which indicated a recommendation that Resident 93 receive two persons assistance with all functional mobility and that the staff was educated on safe transfer technique using forward approach. Nursing progress notes for Resident 93 dated (MONTH) 15, (YEAR), at 9:46 AM revealed the resident was complaining of pain in her right lower leg and that soft tissue swelling was present. An X-ray of Resident 93's right lower leg completed on (MONTH) 15, (YEAR), revealed the resident had a [MEDICAL CONDITION] distal tibia (shinbone that connects the knee and the ankle) and [MEDICAL CONDITION] distal fibula (calf bone, above the ankle). Review of the facility's investigation of Resident 93's fractures dated (MONTH) 19, (YEAR), revealed the resident stated that on the evening of (MONTH) 14, (YEAR), a nurse aide bear hugged her and put her to bed by herself and then fell on top of her. Resident 93 identified the nurse aide who placed her in bed without the assistance of another staff member and fell on top of her. The nurse aide was terminated from the facility. In an interview with the Director of Nursing on (MONTH) 20, (YEAR), at 9:15 AM she indicated the nurse aide was aware of the resident's transfer status, and that Resident 93's fractures occurred due to the nurse aide not following the resident's plan of care. The Director of Nursing indicated that the nurse aide cared for Resident 93 earlier in the shift with two staff members present. The staff saw the nurse aide enter Resident 93's room alone at the end of the shift. The facility failed to ensure that Resident 93 was free from neglect resulting in harm to the resident. 28 Pa. Code 201.18(e)(1) Management Previously cited 5/19/17 28 Pa. Code 201.29(a) Resident rights Previously cited 5/19/17

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to assess and implement interventions in a timely manner to ensure acceptable parameters of nutrition for one of 24 sampled residents (Resident 84). Findings include: The "New Weight Policy," last reviewed August 15, 2012, revealed that all significant weight changes, or weight changes greater than five pounds in seven days would be communicated to the clinical nutrition manager, who will alert the registered dietitian consultant of the significant weight loss/gain. Any weight changes greater than five pounds would be re-weighed the next two days for a total of three days to determine weight accuracy. Clinical record review for Resident 84 revealed nursing documentation starting November 1, 2012, indicating that Resident 84 was nauseous, and presented with vomiting and loose stools. Nursing documentation revealed that Resident 84's nausea, vomiting, and loose stools continued until November 20, 2012, when he was transferred to the emergency room for evaluation. Review of Resident 84's 2012 Weight Record revealed the following weight assessments: November 7, 2012, 207 pounds November 14, 2012, 201.2 pounds (no re-weights to determine weight accuracy) November 17, 2012, 186.4 pounds (20.6 pound, 9.9 percent severe weight loss) November 18, 2012, 187 pounds November 19, 2012, 187.2 pounds November 22, 2012, 170.4 pounds Resident 84 had a 36.6 pound, 17.68 percent severe weight loss in less than a month. Review of Resident 84's nutrition notes revealed that on November 7, 2012, Employee 2 (dietary tech) indicated that Resident 84 had no weight changes from his last review. Employee 2 noted that they would continue to monitor Resident 84. There were no further nutritional notes until November 20, 2012, indicating that Resident 84 was being admitted to the hospital. Interview with Employee 2 and Employee 3 (registered dietitian) on November 29, 2012, at 11:00 AM, confirmed that Resident 84 was a high nutritional risk due to his nausea, vomiting, and diarrhea, and verified that there were no nutritional interventions attempted to prevent his severe weight loss. Employees 3 confirmed that she did not assess Resident 84's nutritional needs regarding his severe weight loss. Interview with the Nursing Home Administrator and Director of Nursing on November 30, 2012, at 11:30 AM revealed that they could provide no further documented evidence that the facility assessed and provided interventions in a timely manner to prevent Resident 84's severe weight loss. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(d)(3)Nursing services. 28 Pa. Code 211.12(d)(5)Nursing services. Previously cited 5/4/12