Every finding on record at Moravian Manor

Based on review of clinical record, facility documentation, and staff interview, it was determined the facility failed to ensure that residents received adequate accident prevention measures by failing to obtain hot beverage temperatures prior to serving resulting in actual harm of a burn caused by hot liquid served for one of four sampled residents (Resident 4). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance.Findings include:Review of Resident 4's diagnosis list revealed diagnoses including vascular dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident 4's Significant Change Minimum Data Set (MDS - periodic assessment of resident needs) dated June 15, 2026, revealed Resident 4 had a Brief Interview of Mental Status Score of 15 indicating resident was cognitively intact. Review of facility documentation dated August 5, 2026, revealed Noted a blister to upper abdomen. Resident reported spilling coffee on self prior and did not report concern until blister formed. Resident reports no pain or discomfort to area. Blister remains intact. Vital signs obtained - within desired limits. Skin assessed for integrity and skin prep placed in TAR (treatment administration record) to protect. MD (physician) and POA (power of attorney) made aware of area of concern. It was not temped prior to serving. The resident is alert and oriented and requests coffee made in the Keurig. We are educating her now that we will need to temp the coffee moving forward. (Resident) did not prepare (resident's) own coffee. Review of facility documentation dated August 5, 2026, revealed During care CNA (certified nurse aide) noticed a blister to resident's upper abd [abdomen] measuring 10 x 20. Nurse was notified. Resident stated that she spilled coffee on herself yesterday. Blister is still intact. Review of facility's Incident Summary dated August 5, 2026, revealed On August 5, 2026, staff identified a blistered area on Resident (4's) abdomen. The resident reported that coffee spilled from [resident's] cup during supper on August 4, 2026. The resident had requested coffee from the Keurig machine; staff brewed the coffee and provided it at supper time. The coffee temperature was not checked before it was served. Interview with Resident 4 on August 18, 2026, at 10:00 a.m. confirmed that staff made coffee for Resident 4 in the Keurig. This interview revealed the coffee was dispensed into a vacuum sealed coffee mug and was given to Resident 4 with the lid in place. This interview further revealed that Resident 4 had removed the lid prior to drinking the coffee and subsequently spilled the coffee onto Resident 4's abdomen. Interview with the Nursing Home Administrator on August 18, 2026, at 10:15 a.m. revealed that the facility received a Keurig coffee machine as a donation and placed the Keurig in a common area for resident use. This interview further revealed the facility had no policy for checking temperatures of liquids from the Keurig prior to serving. This interview further revealed that three other residents occasionally utilized the Keurig with staff assistance. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on August 18, 2026, at 1:05 p.m. for failure to take hot liquid temperatures to prevent accidents and injury to residents which resulted in actual harm of Resident 4. The Nursing Home Administrator was provided with the Immediate Jeopardy template, and an immediate action plan was requested. The facility identified the jeopardy at the time the incident was reported on August 5, 2026, and implemented the following corrective action plan: On August 6, 2026, staff removed the Keurig machines from the care center areas. Skin checks were completed and no other burns were found. A full sweep of the Skilled units was completed, and no other machines were present.One Keurig machine was relocated to the Health Center dining room and used during mealtimes.Dining staff will check the temperature of the coffee prior to serving the residents.Education for the Nursing staff was started on August 6, 2026, with in person and electronic (email and MMC communication app) forms of education. Education was completed by August 10, 2026. Resident was provided with an insulated mug for their coffee.QAPI team was made aware and Plan of Correction added to QAPI. Facility policy implemented on August 6, 2026, titled Keurig Usage Policy revealed Keurig machines may be used on nursing units to prepare beverages for residents when used safely and in accordance with the policy. The Keurig machine will be located in the dining room area; Nursing staff may use the machine to prepare beverages for residents who have provided a kcup to brew; Dining staff will check the beverage temperature before service; Beverages should be maintained at approximately 152-155 degrees before being provided to residents; If the coffee exceeds 155 degrees, it must remain in the dining area until it reaches a safe temperature; Nursing staff will be responsible for all routine Keurig checks and cleaning; There is an instruction sheet and log with the machine. On August 18, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. Eight staff were interviewed and confirmed they received the training described in the facility's action plan. All staff training and education were completed by August 10, 2026. The Immediate Jeopardy existed from August 5, 2026, until August 10, 2026. Verification of all elements of the action plan was completed on August 18, 2026, at 3:05 p.m., and Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Number of residents sampled: Number of residents cited: Based on observations and interview with staff, it was determined that the facility failed to treat each resident with respect and dignity during meal service in one of two dining rooms (Herrnhut).Findings include:Observation on August 26, 2025, at 11:47 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 9.Observations on August 27, 2025, at 11:54 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 19 and Employee E5 wearing disposable gloves while feeding Resident 14.Observations on August 28, 2025, at 11:54 a.m. revealed Employee E6 wearing disposable gloves while feeding Resident 14. Employee E6 was also standing while feeding Resident 14. Employee E3 was standing and wearing disposable gloves while assisting Resident 19. Employee E8 was wearing disposable gloves while feeding Resident 9. An additional observation revealed licensed staff E7 wearing disposable gloves while feeding Resident 37. Interview with the Nursing Home Administrator on August 28, 2025, at 12:55 p.m. revealed that wearing gloves while feeding is not the facility's protocol. Staff should be using good hand hygiene. Additionally, staff should not be standing while feeding residents.

Based on review of the National Fire Protection Agency's (NFPA) 96, observation and interview with staff, it was determined the facility failed to provide an environment free of accident hazards for one of two dining areas. (2nd floor dining room). Findings include: Review of NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations states that open flames are not permitted in health care settings. Observation in the second floor dining room on April 9, 2025 at 11:15 a.m. revealed four hotel pans containing food being warmed by 8 sterno burners (fuel made from denatured and jellied alcohol). Interview with Dietary Employees E3 and E4 on April 9, 2025 at 11:35 a.m. revealed the steam table had broken, and they had been using the sterno to keep the food warm until the steam table was able to be replaced. Further interview revealed the sterno had been used for about a month. Interview with the Nursing Home Administrator on April 9, 2025 at 11:30 confirmed there should not be open flame in the nursing home and instructed the dietary staff to extinguish the sterno flames. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.14 (a) Responsibility of Licensee

Based on a review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of the 18 residents reviewed (Resident 53). Findings include: Review of the facility's policy titled Abuse Investigation, with a review date of May 17, 2023, revealed that all reports of resident abuse, neglect, and injuries of unknown origin are promptly investigated by facility management. The investigation includes interviewing staff members (on all shifts) who had contact with the resident during the alleged incident. Review of Resident 53's diagnosis list includes Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Vascular Dementia with behavioral disturbances. Review of Resident 53's clinical record including the nursing progress notes dated June 20, 2024, at 10:17 p.m., revealed that during the weekly skin assessment, a 20.0 x 9.0 cm (centimeter). yellow bruise area was observed on the resident's right upper arm. The same note also revealed that the resident was combative and resistant to care as observed by the writer on the night the bruise was observed, the physician and the responsible party were notified. Interview with the Director of Nursing on July 31, 2024, at 11:30 a.m., revealed an investigation for an injury of unknown origin is to inlcude statements from staff that had contact with the resident 24 hours before discovering the bruise. Review of the facility's documentation/investigation revealed the facility did not perform a thorough investigation as evidenced by missing statements from several of the staff that cared for Resident 53, 24 hours before discovering the bruise on Resident 53's right upper arm. Interview with the Director of Nursing on July 31, 2024, confirmed the facility did not obtain statements from several staff that cared for the resident within the 24 hours prior to discovering the bruise. The facility failed to ensure Resident 53's bruise of unknown origin was thoroughly investigated. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 9/15/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 9/15/23 28 Pa. Code 201.29(a)(d) Resident Rights Previously cited 9/15/23 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/15/23

Based upon review of clinical records, it was determined the facility failed to ensure resident's code status coincided with resident's wishes and failed to ensure those wishes were identified in resident's medical record for two of 24 residents reviewed (Residents 20 and 49). Findings include: Review of Resident 20's Progress Notes revealed a nursing entry dated June 28, 2023 stating Resident was sent to the hospital on June 26, 2023 at 10:30 p.m. due to a decline in the residents status, residents eyes where rolling in back of head and was very hard to get a response out of, resident heart rate was high as well as blood pressure and the residents hands where blue and arms clenched tight against chest. Resident was belly breathing. Review of Resident 20's POLST (Pennsylvania Orders for Life Sustaining Treatment) signed by the resident and dated March 16, 2018 revealed the resident was a DO Not Resuscitate and wanted comfort measure only including not to send to the hospital for life sustaining treatment only if comfort needs cannot be met. Review of Resident 20's care plan revealed a care plan initiated on January 28, 2020 for receiving only comfort measures and not to be hospitalized . Interview with the Nursing Home Administrator and the Director of Nursing on September 14, 2023 at 1:00 p.m. confirmed Resident 20 was sent to the hospital on June 26, 2023 against the wishes of her POLST. Review of Resident 49's clinical record revealed Resident 49's Living Will indicating Resident 49 was not interested in life sustaining measures in the event of illness. Further review of Resident 49's clinical record revealed a physician's order for Full Code status. Further review of Resident 49's clinical record revealed resident had a Full Code status. Review of Resident 49's Quarterly Minimum Data Set (periodic assessment of resident needs) dated July 20, 2023, revealed a Brief Interview for Mental Status score of 15 indicating Resident 49 was cognitively intact. Further review of Resident 49's clinical record revealed a Physician's Order for Life Sustaining Treatment (POLST) dated February 21, 2020, indicating a Do Not Resuscitate (DNR) status and further indicating full treatment requested. Further review of this POLST revealed it had been voided. Interview with the Director of Nursing and Nursing Home Administrator on September 14, 2023, revealed Resident 49's spouse had a blank POLST in his possession and was in the process of completing the document after speaking with Resident 49. Resident 49 is cognitively intact and able to complete POLST and indicate code status wishes. Interview with the Director of Nursing on September 15, 2023, at 10:00 a.m. revealed Resident 49's spouse had not signed and/or returned the POLST. This interview further failed to reveal the origin of Resident 49's physician order for Full Code status and failed to reveal evidence that Resident 49 was consulted regarding life sustaining treatments. The facility failed to consult Resident 49 regarding code status and life sustaining treatments and failed to ensure Resident 49's clinical record accurately reflected Resident 49's wishes regarding code status and life sustaining treatments. 28 Pa. Code: 201.29 (i) Resident rights. 28 Pa. Code: 211.5 (f) Clinical records. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview it was determined the facility failed to follow recommendation by a would specialist consultant for one of four residents reviewed for pressure ulcers. (Resident 41) Review of Resident 41's progress notes revealed an entry dated July 18 2023 at 11:38 p.m. stating resident with SDTI (Suspected Deep Tissue Injury- brown or black tissues caused by damage due to pressure that is under the skin). Review of Resident 41's Wound care consultant report dated July 21, 2023 revealed the resident had a SDTI and recommended to have an Albumin level (blood test to determine protein in the blood needed for healing). Review of Resident 41's clinical record revealed there was no documented evidence resident 41 had the blood test drawn as recommended by the wound specialist. Interview with the Director of Nursing on September 15, 2023 at 10:35 a.m. confirmed The blood test was not completed as recommended by the wound specialist on July 21, 2023. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to update and revise care plans to reflect resident's current status for one of 24 residents reviewed (Resident 52). Findings include: Review of Resident 52's diagnosis list revealed diagnoses including retention of urine. Review of Resident 52's clinical record revealed Resident 52 was admitted to the facility with a Foley catheter [catheter place to help remove urine]. Further review of Resident 52's clinical record revealed Resident 52's Foley catheter was removed on September 13, 2023. Review of Resident 52's physician orders dated September 13, 2023, revealed Bladder Scan TID [three times per day]; straight cath [catheter utilized for one time use; not to be permanently inserted] with 16F [catheter size] if > [greater than] 350 cc [cubic centimeters]. Review of Resident 52's active plan of care revealed a care plan for Resident 52's Foley catheter. Further review of Resident 52's care plan failed to reveal evidence the care plan was updated to reflect the removal of the Foley catheter and the physician's order for the bladder scan that was to be performed three times per day. Interview with the Director of Nursing on September 15, 2023, at 10:00 a.m. revealed Resident 52's care plan was not updated and/or revised to reflect the discontinuance of the Foley catheter and to reflect the physician's order for the bladder scan to be performed three times per day. The facility failed to update and/or revise Resident 52's care plan to reflect the removal of the Foley catheter and to include the performance of the bladder scan three times per day. Pa. 28 Code 211.11(a)(c)(d) Resident care plan Pa. 28 Code 211.12(b)(c)(d)(1)(3)(5) Nursing services Previously cited 9/29/2022

Based on clinical record review and interviews with staff it was determined that the facility failed to ensure assessments accurately reflect the resident's status for one of two closed records reviewed (Resident 73). Findings include: Review of Resident 73's clinical record revealed a nursing note dated June 30, 2023, indicating the resident was discharged to home with home health services. Further review of the clinical record revealed a discharge Minimum Data Set (MDS-periodic assessment of the residents care needs) was coded as acute hospitalization . Interview conducted with licensed Employee E3 on September 14, 2023 at 1:15 p.m. revealed the discharge MDS assessment was not completed correctly. The facility failed to ensure assessments accurately reflect the resident status for Resident 73. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to notify the State Ombudsman's office of hospitalization of a resident for one of 24 residents reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed Resident 51 was hospitalized on [DATE] and August 5, 2023. Interview with the Director of Nursing on September 15, 2023 at 10:00 a.m. confirmed the State Ombudsman's office was not notified of Resident 51's hospitalization . This interview further confirmed the facility failed to notify the State Ombudsman's office of any hospitalization s or discharges of any resident from September 2022 through August, 2023. 28 Pa. Code 201.18(a)(b)(1)(3) Management

Based on clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 37). Findings include: Review of the facility policy titled Injuries of Unknown Origin, dated January 2021, states, 2. Statements must be obtained from the person reporting the injury and from the caregivers during the past 24 hours and documented. Review of Resident 37's clinical record, reveals a nursing note dated July 20, 2023, an abrasion noted on the top of the right foot measures .5cm x 1 cm, Reddened areas on right great toe measures 0.3 cm and 0.2 cm and l foot 2nd toe 0.2 x0.2 cm. was reported. There was only one documentation from a caregiver in the past 24 hours. Further review of Resident 37's clinical record revealed a nursing note on August 18, 2023, the certified nursing assistant (CNA) alerted the nurse of a bruised area noted on the resident's left buttock, The area measures 3cmx1.7cm in size and is deep purple in color. There was only one documentation from a caregiver in the past 24 hours. Interview with the Director of Nursing on September 15, 2023, 10:35 a.m. confirmed that there was not an investigation with completed statements from the staff. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility policy and procedure, clinical record review and staff interview it was determined that the facility failed to notify resident's representative of medication changes and failed to notify a physician of a resident's weight gain for two out of 24 residents reviewed. (Resident 23 and Resident 225) Findings include: Review of facility policy and procedure titled Protocol for residents with diagnosis of CHF revealed Resident with a diagnosis of CHF will automatically be put on daily weights. Further review of facility policy and procedure revealed the MD [physician] will be notified if there is a three or more pound weight gain in one day or if there is a five or more pound weight gain in one week. Review of Resident 23's diagnosis list revealed diagnoses including Congestive Heart Failure (CHF - excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 23's physician orders dated April 12, 2023, revealed an order for daily weights: notify doctor if there is a 3 pound or more weight gain in 1 day or if there is a 5 pound or more weight gain in 7 days. Review of Resident 23's Weight Summary for August 11, 2023, revealed a weight of 221.2 pounds. Review of Resident 23's Weight Summary for August 12, 2023, revealed a weight of 227.0 pounds indicating a 5.8-pound weight gain in one day. Review of Resident 23's Weight Summary for August 14, 2023, revealed a weight of 220.0 pounds. Review of Resident 23's Weight Summary for August 15, 2023, revealed a weight of 223.6 pounds indicating a 3.6-pound weight gain in one day and a 9.4-pound weight gain in four days. Review of Resident 23's clinical record for August 2023 failed to reveal evidence Resident 23's physician was notified of Resident 23's weight gain on August 12, 2023, or August 15, 2023. Interview with the Director of Nursing on September 15, 2023, confirmed that Resident 23's physician was not notified of Resident 23's significant weight gain. The facility failed to ensure physician was notified of Resident 23's significant weight gain. Review of the clinical record revealed that Resident 224 was admitted to the facility on [DATE], with a diagnosis of Lewy Bodies Dementia (a type of dementia characterized by changes in sleep, behavior, cognition, movement and regulation of bodily fluids). Review of the Physician orders revealed Quetiapine (Seroquel - a medication used to treat certain mental/mood conditions) for hallucinations 50 mg at HS (bedtime) beginning June 29, 2023. Review of the clinical record revealed a nursing note dated August 12, 2023, to monitor resident for sleepiness in dayshift and evening shift before bedtime due to Seroquel changed. Further review revealed a nursing note on August 16, 223, stating that on August 11, 2023, Seroquel was changed from 50mg at bedtime to 25mg twice a day (morning and night), because of behaviors of combativeness and yelling. This was done in a meeting in August that consisted of the medical director, Pharmacist, DON and Social Services, that giving her the Seroquel 50mg at night was not benefiting during the day. There is no mention that the family was notified of the change. Interview with the Director of Nursing (DON) on September 15, 2023, at 8:30 a.m. confirmed the facility had no further documentation that the family was notified of the change. 28 Pa. Code 211.12(b)(c)(d)(3) Nursing Services Previously cited 9/29/2022

Based on observations, review of the clinical record and staff interview, it was determined that the facility failed to obtain a physician's order for oxygen for one of one residents reviewed (Resident 39). Findings include: Observation on September 27, 2022, at 9:55 a.m. revealed Resident 39 was receiving oxygen at 5 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help). Review of the resident's physician's orders revealed no order for oxygen therapy via nasal cannula. Interview with the Director of Nursing on September 29, 2022, at 1:30 p.m. confirmed that there was no physician's order for oxygen therapy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based upon review of facility policy and procedure and clinical record review it was determined the facility failed to thoroughly investigate bruises of unknown origin for one of 18 residents reviewed (Resident 69). Findings include: Review of facility policy and procedure titled Identifying and Reporting Abuse or Neglect, reviewed August 15, 2022 revealed Signs or examples that may represent actual physical abuse: Injuries of an Unknown Source (when such is suspicious due to the extent of the injury or the location or the number of injuries or a pattern of injuries over time) - welts or bruises; abrasions or lacerations; fractures, dislocations or sprains of questionable origin; black eyes or broken tenth; improper use of restraints; sexually exploited; rape; excessive exposure to heat or cold; involuntary seclusion; multiple [CONDITION(S)] or human bites. Review of Resident 69's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 69's progress notes dated September 5, 2022, revealed Writer noted a 2.2 centimeter (cm) x 2 cm fading green/purple bruise to resident's left inner thigh. Skin is intact. Tissue surrounding the area is resident's baseline flesh tone. No redness or inflammation noted. Resident denies c/o [complaints of] pain. Review of Resident 69's progress notes dated September 7, 2022, revealed left inner thigh bruise 3.5 cm x 1.5 cm, right anterior thigh bruise 2 cm x 0.5 cm and right inner thigh 1.5 cm x 1 cm all are green/blue in color. Care plan updated, POA and MD notified. A witness statement provided by Employee E3 dated September 5, 2022, revealed I did not see that before. A witness statement provided by Employee E4 dated September 6, 2022, revealed noticed areas when putting socks on. Another witness statement provided by Employee E3 dated September 7, 2022, revealed I saw the bruise on left thigh in the shower Monday and told the nurse. Review of facility documentation failed to reveal evidence that the above-mentioned bruises on Resident 69 were thoroughly investigated to determine the cause of the bruises. Interview with the Director of Nursing on September 29, 2022, at approximately 10:00 a.m. confirmed that a thorough investigation was not conducted to determine the cause of Resident 69's bruises. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to perform monthly medication reviews for two of 5 residents reviewed. (Resident 5 and 31) Findings Include: Review of Resident 5's clinical record revealed no documented evidence that the pharmacist had performed a medication review for the months of October 2021, December 2021, and February 2022. Review of Resident 31's clinical record revealed no documented evidence the pharmacist had performed a medication review for the months of October 2021, November 2021, December 2021, January 2022, and February 2022. Interview with the Director of Nursing on September 29, 2022, at 1:30 p.m. confirmed there was no documented evidence that medications for Residents 5 and 31were reviewed by a pharmacist for the above months. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(3) Nursing Services

Based on clinical record review and staff interview, it was found that the facility failed to ensure residents were free of significant medication errors, for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's hospital discharge instructions dated February 7, 2020, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's admission note of February 7, 2020, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's progress note of February 12, 2020, revealed resident was sitting in her recliner leaning to the left side. Resident was assessed, eyes were closed and resident did not respond to questions. The physician was notified and ordered stat (immediate) labs including a complete blood count, [MEDICATION(S)] level, [MEDICATION(S)] level, and complete metabolic panel. An order was also received to hold [MEDICATION(S)] tonight. Additional progress note of February 12, 2020, included orders to run IV (intravenous) NSS (normal sterile saline) 0.9% at 200 milliliters/hour, hold [MEDICATION(S)] until further notice and get a basal metabolic panel in the morning stat. Review of FK506 (former name of [MEDICATION(S)]) lab value obtained on February 12, 2020, was 12.3 meq/L (milliequivalent/liter). No definitive therapeutic or toxic ranges have been established. Optimal blood drug levels are influenced by type of transplant, patient response, time post-transplant, co-administration of other drugs, and drug formulation. The following trough range is a suggested guideline: 5.0-20.0 meq/L. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note of February 14, 2020, revealed a call was made to the hospital transplant team to clarify Resident R1's [MEDICATION(S)] dosing. Order received to hold [MEDICATION(S)] for 24 hours, resume [MEDICATION(S)] one mg at bedtime on February 15, 2020, and resume [MEDICATION(S)] 1.5 mg daily in morning on February 16, 2020. Review of the February, 2020, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on November 4, 2020, indicated that in hindsight, the original order should have been clarified. The order was not clear as to whether the resident was to receive three tablets of 1.5 mg for a total of 4.5 mg or a total of 1.5 mg every morning. Clarification was not received from the transplant team until February 14, 2020, at which time it was determined that the resident was to receive 1.5 mg every morning. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of select facility policies and procedures, closed financial record review, and staff interview, it was determined that the facility failed to ensure the understanding of required Notice of Medicare Provider Non-Coverage and for the appeal process for one of three records reviewed (Resident #26). Findings include: The form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- , a notice that informs the recipient when care received from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider, must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months revealed that Resident #26 did not have the form NOMC CMS- signed by the beneficiary or their representative, confirming that the form was given and they understood the appeals process. Interview with licensed nursing staff, Employee E4, on (MONTH) 12, 2019 at 1:49 p.m confirmed that the facility could not show documented evidence that Resident representative received or signed the NOMC CMS- notice. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, facility documentation review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent accidents to the resident causing actual harm, when the resident fell and sustained a nasal fracture, to one of three residents reviewed (Resident R1). Findings Include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's Quarterly Minimum Data Set assessment (MDS- periodic assessments of resident needs), dated (MONTH) 17, (YEAR), revealed that Resident R1 required extensive assistance of two people to transfer and toilet. Review of Resident R1's Rehab Discharge Program for Occupational Therapy dated (MONTH) 29, (YEAR), revealed the resident was impulsive and had impaired balance with sitting and standing, and required supervision while seated on the toilet and in the wheelchair or on the edge of bed. Review of Resident R1's revealed a care plan for falls with interventions to encourage the resident to be in the common areas when in the wheelchair for increased supervision and to keep the resident in the living area when in the wheelchair and not supervised in the room. Review of resident R1's progress notes revealed an entry on (MONTH) 27, 2019, at 2:17 p.m. stating the resident was found in her room laying on her stomach on the floor. Her nose was bleeding. Resident states that she dropped her candy on the floor and leaned forward and try to pick it up and fell to the floor. Review of the facility investigation of the incident revealed that Resident R1 was in the east lounge and self-propelled herself in her wheelchair back to her room following another resident toward the dining room and stopped in her room for candy. A CNA (nurse aide) saw resident in the room with candy in her hand, resident states that she wanted to eat her candy before going to the dining room for supper. The CNA (nurse aide) went to answer a call bell and when she came back 5 minutes later resident was on the floor. Resident states that she dropped her bag of candy on the floor and she leaned forward to try to pick it up and fell out of her wheelchair. Review of documentation submitted by the facility dated (MONTH) 5, 2019, revealed that the resident had an x-ray of the nose on (MONTH) 28, 2019, which showed a [MEDICAL CONDITION] bone. Interview with the Director of Nursing at approximately 2:00 p.m. on (MONTH) 14, 2019, confirmed that the facility staff failed to follow Resident R1's care plan intervention of not being left unsupervised in the room in the wheelchair which resulted in the resident falling out of the chair and sustaining a fracture. The facility failed to provide supervision to the resident as care planned to prevent falls which resulted in Resident R1 falling and causing a nasal fracture. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 11/09/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/09/18 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 11/09/18 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/09/18

Based on review of facility policy, review of clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure residents were free of accidents during a transfer via a mechanical lift to one of 22 residents reviewed (Resident #42). Findings include: Review of the facility policy labeled Resident Handling: Full Body Lift Resident Transfers, dated (MONTH) (YEAR), revealed that section II. Full Body Lift Usage states Secure the slings onto the lift cross bars using safety clips as designed. Ensure all safety features are in use; Widen base of lift as needed for added stability; Secure the resident's arms and legs for transfer; Grasp the steering handles of the floor lift to move the resident into position over chair/wheelchair/commode/bed. Review of Resident #42's clinical record revealed the following, but not limited to, diagnoses; nontraumatic [MEDICAL CONDITION] (bleed that occurs within the brain tissue), [MEDICAL CONDITION] (a disorder of the central nervous system characterized by partial or total loss of the ability to communicate), flaccid [MEDICAL CONDITION] affecting left side (Severe or complete loss of motor function on one side of the body), [MEDICAL CONDITION] (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain), and scoliosis (a spine condition that occurs when the spine curves or twists to the side). Further review of Resident #42's clinical record revealed a Quarterly Minimal Data Set assessment (MDS- assessment of resident care needs) dated (MONTH) 12, (YEAR), which identified the resident in Section B: Hearing, Speech and Vision as rarely/never understands and rarely/never understood . Further review of the assessment indicated on Section C: Cognitive Patterns that the resident had severe cognitive impairment. Review of Section G: Functional Status revealed that for transfers the resident required total dependence and must have two persons for physical assist. Resident #42 was also noted, in this section, to not have any activity for walking in the room or corridor)and was total dependent for moving between locations. Review of Resident #42's clinical record revealed a nursing note dated (MONTH) 5, (YEAR) stated that Resident #42 had fallen from a lift sling. Facility Report event dated (MONTH) 5, (YEAR), stated two staff members were transferring the resident from bed to Broda chair (a high back chair used for positioning) via Hoyer lift (a mechanical device designed to lift patients safely) when the resident leaned to the right side and fell head first onto the floor and obtained a skin tear on the right forehead. Review of the facility investigation of the event revealed interviews with the staff members. Review of the interview statements revealed nursing staff, Employee E3 acknowledged that a safety check was not done prior to doing the lift with the resident. Employee E4 revealed that she pulled on the sling while transferring the resident and that she did not widen the lift legs prior to the transfer. Further review of the interview statements revealed that nursing staff, Employee E4 heard a snap and the strap of the right leg came off and the resident fell . Review of the skin assessment dated (MONTH) 5, (YEAR), revealed that the resident received a skin tear over the right brow measuring 3 centimeters (cm) x 2cm, cleansed with NSS (normal saline solution), steri-strips applied (adhesive skin closures that are used to close cuts that are too deep for a bandage but not bad enough to require stitches), covered with [MEDICATION NAME] (an absorbent dressing made from [MEDICATION NAME] foam), and ice applied x 15 minutes. An interview was conducted on (MONTH) 9, (YEAR), at approximately 2:15 p.m., where the Nursing Home Administrator concurred that the staff members failed to follow facility policy by performing safety checks, moving the swing with the steering mechanism and widening the legs for stability, resulted in Resident #42 fall with minor injury. The facility failed to ensure Resident #42 was free of accidents during a transfer via a mechanical lift which resulted in a fall with minor injury. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of Resident clinical record review, staff interview, and policy review, the facility failed to establish clear advance directives , proper utilization of the POLST (Pennsylvania Orders for Life Sustaining Treatment form), and proper code determination for 7 of 24 residents (Resident ' s D1, F3, H2, J3, K7, K10 and CL1 ). Findings include: According to the facility ' s policy, POLST Policy effective [DATE], states: The facility supports the rights of residents to direct (in making) decisions regarding their care and treatment. In accordance with federal and state law, the facility will provide all residents with written information regarding their right to make and participate in treatment decisions concerning medical care to be provided for the resident, including the right to accept or refuse medical or surgical treatment. Unlike an Advanced Directive or Living Will, which describes the medical wishes for end of life, the POLST turns these wishes into physician orders [REDACTED]. Procedure includes: Admissions will place a copy of the POLST form plus explanation in the admission packet, determine if the resident has an appropriate Advance Directive, POA, and POLST and request that copies be brought in to be placed into the resident ' s record; Social services and/or nursing will present the attending physician with the POLST form and if it is not completed, the physician will present and review the POLST form with the resident/responsible party, completing it according to the resident ' s wishes; Nursing ensures the physician has signed and dated the document; the Attending physician reviews resident Advance Directives, POA, and POLST and discusses end of life treatment decisions with the resident or his surrogate when the resident lacks capacity . According to www.polst.org <http://www.polst.org>, the POLST form (physician's order [REDACTED]. A POLST form provides medical orders for current treatment and guides actions of medical personnel in a life threatening situation when a person is established a DNR (Do not resuscitate) or a Full Code (CPR (cardiopulmonary resuscitation - artificial breathing and chest compressions when a person has stopped breathing and/or heart has stopped- and other life- saving interventions will be used to try to prevent death). An Advance Directive provides instructions for future treatment if a person becomes unable to make their own healthcare decisions. Review of Resident D1 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. the overuse of alcohol, resulting in loss of reality contact and functioning ability) and dysphagia (trouble swallowing food and liquids). Review of Resident D1 ' s clinical medical record revealed a POLST form located at the front of the clinical record. Review of the POLST form indicated that the resident ' s wife had signed and completed the form indicating that Resident D1 would be a DNR with no life support. There was no date indicating when the resident ' s wife completed and signed the form. There was no physician's signature present on the form, rendering the POLST form invalid for usage. Review of Resident F3 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. breath and lethargy). Review of Resident F3 ' s clinical medical record revealed that the resident had a POLST form signed by the resident ' s Power of Attorney (POA) on [DATE] indicated that the resident was a DNR (Do Not Resuscitate). Review of the resident's quaterly assessment dated [DATE] identified the resident as cognitively intact. Review of the clinical medical record revealed that on [DATE] the resident was deemed incapacitated by the county and was assigned a legal guardian with the revocation of the POA ' s rights. Review of the clinical medical record revealed that the resident did not have an Advance Directive and there was no documentation that advance care planning was discussed with the resident, or if the POLST form was discussed with the resident at the time her POA signed it. Review of the clinical medical record also did not reveal if a new POLST was formulated after the POA was no longer her Power of Attorney and the legal guardian service was notified and discussed with them. Interview with Employee E3 on [DATE] at 12:30 p.m. confirmed that there was no documentation in regard to discussing with the resident, the POA and the legal guardian in regard to the resident advance care planning and code status. Review of Resident H2's clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].- poor circulation of the extremities), [MEDICAL CONDITIONS] (a reduction in red blood cells),[MEDICAL CONDITION](reflux disease), Major [MEDICAL CONDITION] (caused by deterioration of the central portion of the retina (sends signals to the brain for visual recognition) and [MEDICAL CONDITION] (kidney failure). Review of Resident H2's clinical medical record revealed a General Power of Attorney which appointed Resident H2's son for financial concerns only was signed by the resident on [DATE]. A POLST form was signed by the resident's son on [DATE] and designated the resident a DNR. However, the resident's son was not appointed by the resident to make medical decisions for the resident and review of Resident H2's comprehensive assessment dated [DATE] revealed the resident was cognitively intact to make her own decisions. Review of Resident J3 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident ' s clinical medical record revealed that the resident ' s family member was the resident ' s financial POA. Review of resident J3 ' s clinical medical record revealed that there was a physician's order [REDACTED]. Review of the resident ' s clinical medical record revealed that there was no living will or advance care planning from the resident completed, no POLST on the clinical record, and no documentation indicating that advance care planning information was offered to the resident and/or his family. Review of Resident K7 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical medical record revealed that the resident's clinical record did not contain a POLST form, any advance directives or living will, but the resident had a physician's order [REDACTED]. Review of the physician ' s progress notes dated [DATE] under the advance care planning section stated, [DATE] family states that there are documents, but they are not available today. DNR per facility chart. Family has request no lab draws at this time. Will reassess in the future. POLST has not been completed by family. Interview with Employee E4 on [DATE] at 1:00 p.m. confirmed that there was no documentation from the physician, nursing or social services that a code status was discussed at the time of admission with the family or resident. Review of Resident K10 ' s clinical medical record revealed that the resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical medical record revealed that the resident has a POA. Review of the clinical medical record revealed a physician's order [REDACTED]. Review of the resident's clinical medical record revealed that the resident was admitted to Hospice services on [DATE]. Review of the clinical medical record revealed two POLST forms in the front of the clinical record, one dated [DATE] and [DATE] that were both signed by a physician, but no signature from the POA indicating the POLST were not valid. Review of the resident clinical medical record did not contain any documentation that the facility and the POA had a discussion in regard to the advance care planning of Resident K10. Review of resident CL1 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] and passed away at the facility on [DATE]. Review of the clinical medical record revealed that the resident was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the clinical medical record revealed that there was a physician order [REDACTED]. Review of the resident's clinical record revealed a social service note dated [DATE] stating, Social worker unable to locate a living will or other advance directive. There is a POLST form on her chart to be completed with physician visit. Review of the clinical medical record revealed an admission MDS completed on [DATE] and revealed that Resident CL1 ' s BIMS was a 15 indicating the resident was cognitively intact. Review of the clinical medical record did not reveal that there was any documentation that advance care planning or code status was discussed with the resident. Interview with Employee E3 on [DATE] at 12:30 p.m. confirmed that there was no documentation that advance care planning and code determination was discussed with the resident while at the facility. 28 Pa Code 201.18(b)(1)(2)(3)(b)(1) Management Previously cited: [DATE] 28 Pa Code 211.5(f) Clinical Records Previously cited: [DATE] 28 Pa Code 211.12(c)(d)(1)(5) Nursing Services Previously cited: [DATE]

Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to monitor behaviors and medication side effects for the use of [MEDICAL CONDITION] medications for 14 of 24 residents (Resident A2, A8, B3, C6, D1, E6, E7, F3, H2, J3, J4, K7, K10 and CL1) and failed to provide appropriate medical [DIAGNOSES REDACTED]. Findings include: Review of the facility's policy, Residents with Distressing Behaviors dated October 14, 2013 indicated: The facility provides for a comprehensive behavioral health program to the residents we serve. This program offers a multi-faceted approach to managing behaviors that includes: Assessment and identification of behaviors that are distressing to the resident or others, behaviors that place the resident or others for risk of harm, and/or behaviors which communicate a resdient need. Assessment and identification of root causes for behaviors; creation of resident centered and specific interventions for behavioral symptoms and subsequent care planning of identified, appropriate interventions; assessment identification of symptoms and management of conditions such as depression, [MEDICAL CONDITION], medication side effects, metabolic disorders, infections and other potential medical contributors to distressing behaviors. Behaviors that are distressing to a resident or others will be tracked and trended to assess for patterns, potential triggers, and evaluated for specific and effective resident centered interventions. Behaviors may be tracked by direct caregivers, or a seven day period, using tracking forms. Review of the facility's policy, [MEDICAL CONDITION] Medication Monitoring last update January 2013 indicated: Residents receive [MEDICAL CONDITION] medications only when medically necessary. Every effort is made to ensure that residents who use these medications receive the intended benefit of the medications and to minimize the unwanted side effects of the medications. Residents receive an antipsychotic medication only if one of the following [DIAGNOSES REDACTED]. described (e.g. biting, kicking, scratching, etc.) by the facility that causes the resident to represent a danger to self and/or others; psychomotor symptoms not exhibited as specific behaviors, but that causes the resident subjective distress (excessive fear); specific behaviors and psychotic symptoms must be documented quantitatively and described objectively. If there is no response as indicated by quantitative and objective measures, a gradual dose reduction will be attempted. Review of Residents A2, A8, B3, C6, D1, E6, E7, F3, H2, J3, J4, K7, K10 and CL1 revealed the use of the following a [MEDICAL CONDITION] medications: [REDACTED]. The antidepressant medications include: [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. The antipsychotic medications include: [MEDICATION NAME] and [MEDICATION NAME]. The antianxiety medications included: [MEDICATION NAME], Klonopin, [MEDICATION NAME] and [MEDICATION NAME]. Review of the clinical medical records for the above stated residents did not indicate any documentation that included specific monitoring of side effects for any psychiatric medications on a regular basis and no specific target behavior tracking indicating why the medications were being utilized for the resident. Interview with Employee E3 on January 5, 2016 at 11:30 a.m. confirmed that there was no specific documentation requirements that the facility used for the tracking of side effects of the above [MEDICAL CONDITION] medications and specific documentation for individualized target behaviors for the use of psychoactive medications. Employee E3 stated that the licensed nursing assistants have the capability to place behaviors into the clinical documentation, but they are not specific to why the resident was prescribed a psychoactive medication. Review of Resident D14's clinical medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident D14 ' s electronic clinical medical record revealed that the resident was order the antipsychotic medication [MEDICATION NAME] (a medication used to control paranoid thinking, delusional thinking and/or hallucinations) 25 milligrams at bedtime for the [DIAGNOSES REDACTED]. Review of Resident F3 ' s clinical medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].), and muscle weakness. Review of Resident F3 ' s electronic clinical medical record revealed that the resident was ordered by the physician the antipsychotic medication [MEDICATION NAME] (an antipsychotic medication that used for mental health to control paranoid thinking, delusional thinking and/or hallucinations) 0.5 milligrams as needed every 2 hours for the [DIAGNOSES REDACTED]. Review of J 3' s' clinical medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of J3 ' s electronic clinical medical record revealed that the resident was ordered by the physician [MEDICATION NAME] 50 milligrams three times a day for the [DIAGNOSES REDACTED]. Interview with Employee E3 on January 7, 2016 at 1:30 p.m. confirmed that the [DIAGNOSES REDACTED]. 28 Pa Code 211.5(f) Clinical Records Previously cited: 11/6/2014 28 Pa Code 211.10(a) Resident Care Policies Previously cited: 11/6/2014 29 Pa Code 211.12(d)(2)(3)(5) Nursing Services Previously cited: 11/6/2014