Every finding on record at Normandie Ridge

Based on review of facility policy, staff interviews, and clinical record review, it was determined that the facility failed to discuss the risks/benefits and obtain consent for antipsychotic medications for three of five residents reviewed for unnecessary medications (Residents 4, 5, and 38). Findings include: Review of facility policy Psychotropic Medications, date reviewed April 2026, read, in part, facility will obtain informed consent from the resident and/or resident representative. Consents and any psychotropic medications will be reviewed quarterly at resident care conference. Review of Resident 4's clinical record documented diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking) and depression (feelings of severe despondency and dejection). Further review of Resident 4's clinical record documented he was admitted to the facility on [DATE]. Review of Resident 4's physician orders included: Buspirone 5 mg every morning and bedtime for agitation, start January 24, 2025; Seroquel 25 mg at bedtime for agitation, start March 14, 2025, and discontinue March 25, 2025; and Seroquel 25 MG in afternoon and at bedtime for agitation, started March 25, 2025. Review of Resident 4's Informed Consent for Use of Psychoactive Medication document dated January 13, 2025, failed to contain a drug name, or the risks and benefits of utilizing the medication. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 19, 2026, at 10:40 AM, the concern regarding the consent and risk/benefit information not being inclusive of the required information was discussed and no further information was provided. Interview with the NHA and DON on August 19, 2026, at 1:00 PM, it was revealed that the Informed Consent for Use of Psychoactive Medication form is completed upon admission. It was also revealed that Resident 4 is followed by psychiatry services and the provider does communicate with Resident 4's wife, and when the Seroquel was initiated, staff communicated with the wife regarding the risks and benefits via phone. Review of Resident 5's clinical record revealed diagnoses that included depression, bipolar disorder (a lifelong mental health condition that causes extreme shifts in in mood, energy, activity levels, and daily functioning), and anxiety (a normal human emotion characterized by feelings of tension, worried thoughts, and physical changes, such as a fast heartbeat). Review of Resident 5's physician orders revealed the addition of mediations that included: Prozac, 40 MG once per day dated August 3, 2026; Klonopin 1 MG every 8 hours as need and every 12 hours as needed dated August 5 and 15, 2026, respectively; and Risperdal, .5 MG 3 times per day dated August 14, 2026. Review of Resident 5's clinical record revealed a consent for psychotropic medications dated at the date of her admission in 2025. Review of the clinical record revealed no risk/benefits and consent reviewed with the Resident or her Representative with the addition of the medications ordered in August 2026. An interview with the NHA on August 20, 2026, at 10:04 AM, revealed there were no new consents for Resident 5's current psychotropic medications Review of Resident 38's clinical record documented diagnoses that included depression, vascular dementia with psychotic behaviors, and severe mood disturbances. Review of Resident 38's physician orders included Seroquel 37.5 mg at bedtime, started November 10, 2025, and discontinued April 22, 2026; and Seroquel 50 mg at bedtime for vascular dementia with psychotic behaviors, started April 22, 2026. Review of Resident 38's Informed Consent for Use of Psychoactive Medication document, dated May 4, 2026, failed to contain a drug name or the risks and benefits of utilizing the medication. During an interview with the NHA and DON on August 19, 2026, at 10:40 AM, the concern regarding the consent and risk/benefit information not being inclusive of the required information was discussed and no further information was provided. 28 Pa. Code 201.29 Resident rights

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of three nursing units (Sunflower nursing unit).Findings include: Observation on August 17, 2026, at 10:56 AM, in Resident 4's room, revealed a maroon floor mat to the right of the bed that contained 2 V shaped tears on the top and two corners were pealed back exposing the foam. Additional observation on August 18, 2026, at 2:00 PM, with the Nursing Home Administrator (NHA) revealed the floor mat to the right of the bed remained in the same condition. Interview with the NHA, at that time, revealed the floor mat will be replaced. Interview with the NHA on August 19, 2026, at 10:45AM, was revealed that any staff member should've noticed the floor mat needed to be replaced and submit a request for maintenance. Additional interview with NHA on August 19, 2026, at 1:14 PM, revealed the floor mat was replaced, and the task had been added to the night shift rounds to observe floor mats. 28 Pa. Code 201.18 (e)(1)(2.1) Management

Based on policy review, review of select food service committee meeting minutes, resident and staff interviews, observations, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.Findings include: Review of facility policy, titled Quality and Palatability, not date marked, read, in part, food is palatable, attractive and served at a safe and appetizing temperature. Interview with Resident 21 on August 17, 2026, at 11:14 AM, it was revealed he doesn't think the food tastes good, and the hot food isn't hot. He eats in his room for breakfast and in the main dining room for lunch and dinner. Interview with Resident 56 on August 17, 2026, at 11:32 AM, revealed the food isn't hot at all meals, and she eats in her room per her choice. Review of the Food Service Committee meeting minutes dated June 10, 2026, revealed resident feedback included some food items aren't served hot enough. A test tray was completed on August 18, 2026, that revealed adequate portions size and the food was palatable for taste and texture for a regular diet; however, the temperature of the beef stroganoff, noodles and sugar snap peas weren't palatable for temperature. The test tray was prepared from the steamtable in the main dining room upon completion of service to the residents in the dining room; 47 minutes had elapsed between the time lunch service was initiated in the [NAME] Hall dining room and the test tray was prepared from the steam table in the main dining room and presented for evaluation. Employee 6 (Food Service Manager) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: beef stroganoff - 128 degrees Fahrenheit (F)parslied buttered egg noodles - 128 degrees Fsugar snap peas - 128 degrees Ftossed salad - 65 degrees Fchocolate brownie - was served at room temperaturecranberry juice - 46 degrees FCoffee - 155 degrees F Interview with Employee 7 (Regional Food Service Manager) on August 18, 2026, at 1:00 PM, revealed he turned the temperature up on the steam table and felt the hot food temperatures could've been warmer on the steam table. Interview with the Regional Manager on August 18, 2026, at 1:46 PM, it was revealed that his comfort level for hot food temperature at time of service is 135 degrees F. Interview with Nursing Home Administrator on August 19, 2026, at 1:14 PM, revealed hot food should be served at a palatable temperature 28 Pa. Code 201.14. Responsibility of licensee28 Pa code 211.6 - Dietary services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to distribute and serve food under sanitary conditions for one of two meals observed (August 18, 2026, lunch).Findings include: Review of facility policy, titled Infection Control- Hand Hygiene, reviewed August 18, 2026, read, in part, the use of gloves doesn't replace hand washing/hand hygiene. Observation in the main dining room on August 18, 2026, at 12:39 PM, revealed Employee 7 (Regional Food Service Manager) donned a pair of gloves, without completing hand hygiene. He then proceeded to touch the serving utensils on the steam table and obtain the temperature of the hot foods. He then proceeded to reach inside his pocket, retrieved his phone, made a phone call, reached under the steam table and adjusted the knobs, reached inside his pocket and retrieved an alcohol swab, cleaned the thermometer, removed his gloves, and completed hand hygiene. Additional observation in the main dining room on August 18, 2026, at 12:50 PM, revealed Employee 8 (Cook) was serving hot food from the steam table utilizing serving utensils and gloved hands. He then proceeded to open the refrigerator door and remove a tray with sliced bread and ham. With the same gloved hands, without changing gloves and completing hand hygiene, touched the sliced bread and ham in the process of making two ham sandwiches. He then returned to serve hot food from the steam table. Interview with Employee 7 on August 18, 2026, at 1:02 PM, it was revealed that Employee 8 should've changed gloves and completed hand hygiene prior to making the sandwiches. Interview with Nursing Home Administrator on August 19, 2026, at 1:14 PM, revealed Employees 7 and 8 should've completed appropriate hand hygiene. 28 Pa code 211.6(f) - Dietary Services

Based on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement enhanced barrier precautions to prevent the spread of infection for one of five residents reviewed with chronic wounds (Resident 16).Findings Include: Review of facility policy, titled Standard and Transmission-Based Precautions, revised September 11, 2025, revealed in a section labeled Enhanced Barrier Precautions, The precautions also apply to residents with chronic wound or indwelling medical devices, regardless of their MDRO (multidrug-resistant organism) status, and to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO with contact precautions do not apply. Enhanced Barrier Precautions include the use of PPE (gowns and gloves) during high-contact resident care activities. Review of Resident 16's clinical record revealed diagnoses that included Chronic kidney disease (gradually impairs kidney function, often without early symptoms, and can lead to serious complications like heart disease and kidney failure if untreated) and diabetes (a condition where the body is unable to regulate blood glucose levels). Observation of Resident 16 on August 19, 2026, at 10:25 AM, revealed Resident 16 lying in her bed. Hanging on the wall outside of Resident 36's room was a sign indicating that Resident 16 was on Enhanced Barrier Precautions. At that time, Employee 9 completed a dressing change on Resident 16's pressure ulcer without wearing a gown, which would be required for residents on Enhanced Barrier Precautions. Review of Resident 16's physician orders revealed an order for a dressing change for a pressure injury on the Resident's sacrum, starting August 7, 2026. Further review failed to reveal an order for Enhanced Barrier Precautions. Review of Resident 16's care plan revealed a focus area of, Resident has actual impairment to skin integrity of sacrum DTI, with a revision date of August 7, 2026. Further review of the care plan failed to reveal any expectations of following Enhanced Barrier Precautions when providing care to Resident 16. Interview with the Nursing Home Administrator on August 20, 2026, at 10:10 AM, revealed that she would expect the facility policy and regulations to be followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of pressure injuries for one of two residents reviewed for pressure injuries (Resident 71).Findings include:Review of facility policy, titled Skin Management and Injury and Prevention, last reviewed July 30, 2025, revealed the policy statement was, B. A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing. Subsection I. stated, All resident alterations in skin integrity will be tracked weekly in the [Electronic Medical Record] and reviewed and documented weekly until resolved.Review of Resident 71's clinical record revealed diagnoses that included acute congestive heart failure (decreased ability of the heart to effectively pump blood throughout the body) and unspecified atrial flutter (irregular heart rate).Review of Resident 71's clinical record revealed that upon re-admission to the facility from a hospital stay on August 8, 2025, Resident 71's sacral area was identified as having intact, dry skin.Review of Resident 71's interdisciplinary progress notes revealed that on August 16, 2025, at 2:48 PM, Employee 4 (Licensed Practical Nurse [LPN]) documented Resident 71 had an open area to left upper buttocks that was approximately 1.0 centimeter (cm - metric unit of measure) by 0.7 cm. The wound bed was documented as having yellow slough (dead cells and/or tissue). The progress note stated that the supervisor was made aware. Further review of the clinical record revealed no progress note or assessment of the newly identified wound was completed by a Registered Nurse. Resident 71's physician's orders, revealed that an order was started to cleanse the wound with Normal Saline Solution (NSS), apply medical honey and cover with boarder gauze.Review of Resident 71's clinical record revealed that the electronic skin/wound assessment tracking form was not initiated until August 25, 2025. Review of Resident 71's clinical record failed to reveal a documented wound assessment (including but not limited to wound size, characteristics, or changes and or improvement) for Resident 71's sacral wound between August 16 and 25, 2025 (total of 9 days).Between the dates of August 16 and 25, 2025, Resident 71 was transferred to a hospital emergency department on August 21, 2025, at approximately 1:04 PM due to abnormal blood laboratory values, and returned to the facility on August 21, 2025, at approximately 7:50 PM. Review of Resident 71's clinical record revealed no reassessment of Resident 71's skin upon return to the facility.On August 25, 2025, at 11:24 AM, Employee 5 (Registered Nurse) documented a wound assessment. According to the wound assessment, Resident 71's sacral wound measured 5.33 cm in length by 1.42 cm in width.During a staff interview on September 26, 2025, at approximately 2:30 PM, the Nursing Home Administrator confirmed that there was no documented wound assessment completed for Resident 71's sacral wound between August 16 and 25, 2025. As of the interview, the facility had no further information to provide.28 Pa code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of two residents reviewed on Transition Based Precautions (Resident 29).Findings include: Review of facility policy, Standard and Transmission Based Precautions, last revised September 27, 2024, read, in part, transition-based droplet precautions signage documented to wash hands prior to entering and upon exiting the resident's room, and reusable equipment should be sanitized. Review of Resident 29's clinical record documented diagnoses that included chronic respiratory failure with hypoxia (the lungs cannot effectively take in enough oxygen to meet the body's needs) and chronic obstructive pulmonary disease (lung diseases characterized by persistent airflow obstruction and inflammation in the airways). Further clinical record review documented physician orders that included Droplet Precautions with Respirator: MSSA (methicillin susceptible staphylococcus aureus - a type of bacteria that has become resistant to many common antibiotics, making it harder to treat) in the lungs, all care and treatments to be completed in room, started September 12, 2025; and cefazolin 2 gram intravenously every 8 hours for pneumonia administer over 30 minutes, started September 2, 2025, until October 6, 2025. Observation on September 22, 2025, at 11:38 AM, outside of Resident 29's room was a sign to the left of the doorway that read, in part, droplet with respirator precautions - wash hands before entering and when exiting, wear a masks and eye protection. Associates wear a fit-tested respirator inside the room and remove after exit. Use dedicated or disposable equipment/supplies. Visitors wear a mask in the presence of others and anytime you're out of your loved one's room. Additional Observation on September 22, 2025, at 11:57 AM, revealed Employee 2 (Housekeeper) entering Resident 29's room wearing a gown, gloves, face mask and face shield. At 12:00 PM, Employee 2 exited the room with the aforementioned Personal Protective Equipment (PPE), unlocked the cleaning cart, disposed of a floor cleaning pad, obtained another floor cleaning pad, and reentered the room. At 12:01 PM, Employee 2 exited the room with the aforementioned PPE, removed the floor cleaning pad, hung the mop handle on the cart (did not sanitize the mop handle), and re-entered the room. Employee 2 exited the room without a gown or gloves, removed the mask and face shield, discarded them in the trash bag hanging from the housekeeping cart, and did not complete hand hygiene prior to exiting the unit. During an interview with the Nursing Home Administrator on September 25, 2025, 11:30 AM, it was revealed that Employee 2 should've doffed the face shield and face mask prior to exiting Resident 29's room, hand hygiene should've been completed once all PPE was removed, and the infection control policy/Droplet precaution instructions should be followed. 28 Pa code 211.10(d) Resident care policies28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review, review of facility provided documentation and reports, and resident and staff interviews, it was determined that the facility failed to ensure sufficient staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 19 residents reviewed (Resident 213). Findings include: Review of Resident 213's clinical record revealed diagnoses that included obesity and urinary tract infection. Review of Resident 213's care plan revealed a focus for activities of daily living self-care performance deficit related to impaired balance and fatigue with an intervention for limited assistance of one person for toileting, dated July 31, 2024. In addition, the care plan revealed a focus for limited physical mobility related to weakness and acute hospitalization with an intervention for assist of one person with a rolling walker for ambulation, dated July 31, 2024. During an interview with Resident 213 on August 5, 2024, at 12:37 PM, Resident 213 indicated that the Resident cannot get out of bed without staff assistance to go to the bathroom, often wait a long time to get their call bell answered, and the Resident soiled themselves this morning while waiting for someone to come and answer the call light. Review of facility provided report, titled Device Activity Report, from August 5-7, 2024, for Resident 213 revealed the following: 1) on August 5, 2024, at 8:28:50 AM, their call bell alarmed and was cleared at 9:00:22 AM, a total of 31 minutes and 32 seconds; 2) on August 5, 2024, at 6:33:07 PM, their call bell alarmed and was cleared at 6:58:58 PM, a total of 25 minutes and 51 seconds; 3) on August 7, 2024, at 1:57:30 PM, their call bell alarmed and was cleared at 2:48:17 PM, a total of 50 minutes and 47 seconds; and 4) on August 7, 2024, at 6:51:22 PM, their call bell alarmed and was cleared at 7:24:16 PM, a total of 32 minutes and 54 seconds. Review of facility provided staffing information from August 1-7, 2024, revealed that on August 5, 2024, for day shift the census was 62 and that the facility needed a minimum of 49.60 hours for nurse aides, and they provided a total of 48 hours; therefore, not meeting the minimum hours needed based on the facility census. In addition, the facility needed a minimum nurse aide ratio of 6.20 and provided 6.00; therefore, not meeting the required ratio of nurse aides based on facility census. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 8, 2024, at 10:04 AM, the NHA confirmed they were not able to meet staffing ratios on August 5, 2024, for day shift. In an email communication received from the NHA on August 8, 2024, at 12:39 PM, she indicated, I would expect [Resident 213's] light to be answered sooner. No other information was provided for review. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(5)(f.1)(3) Nursing services

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed ensure as needed psychotropic drugs are limited to 14 days or have documented rationale and duration for one of five residents reviewed (Resident 1); and failed to ensure effects and side effects of psychotropic medications were being monitored for one of five residents reviewed (Resident 56). Findings include: Review of facility policy, Psychotropic Medications, revised December 4, 2023, revealed, PRN [as needed] orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Review of Resident 1's clinical record revealed diagnoses that included anxiety (a feeling of fear, dread, and uneasiness) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and/or daily routine). Review of Resident 1's physician's orders dated August 5, 2024, revealed a current order for Lorazepam (antianxiety/psychotropic medication) 0.5 mg to be given every eight hours, as needed, that was ordered on July 11, 2024, without stop date. Review of Resident 1's clinical record on August 7, 2024, failed to reveal a rationale and duration, documented by the physician, for the PRN psychotropic medication to extended beyond 14 days. Interview with the Nursing Home Administrator (NHA) on August 7, 2024, at 11:32 AM, revealed that the expectation is that the physician would limit the use of the PRN psychotropic medications to 14 days or document the rationale for the extended order, as stated in the facility policy. Review of Resident 56's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of Resident 56's clinical record revealed an active physician's order for Haloperidol 0.5 milliliters orally two times a day for terminal agitation, with an active date of May 2, 2024; an order for Lorazepam Oral Tablet 0.5 milligram one tablet by mouth at bedtime for anxiety, with an active date of April 1, 2024; an order for Duloxetine 30 milligram capsule one time a day for depression, with an active date of April 1, 2024; and an order for Bupropion 75 milligram tablet, two tablet orally two times a day for depression, with an active date of April 1, 2024. Further review of Resident 56's physician's orders also reveal an order to observe closely for significant side effects of anti-anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift document: 'Y' if monitored and none of the above observed, 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings, with a start date of April 1, 2024. Review of Resident 56's physician's order also reveal an order to observe closely for side effects of antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift documents: 'Y' if monitored and none of the above are observed, 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings, with a start date of April 1, 2024. Review of Resident 56's May 2024 TAR (Treatment Administration Record), June 2024 TAR, July 2024 TAR, and August 2024 TAR revealed that staff documented a check mark during day, evening, and night shift for the entire month for the observation orders above, which does not accurately reflect if Resident 56 is displaying any side effects from the psychotropic medications the Resident is being administered. Review of Resident 56's clinical record revealed no nurses' progress notes indicating if Resident 56 is displaying any behaviors from the psychotropic medications they are being administered. During an interview with the NHA and the Director of Nursing on August 8, 2024, at 12:13 PM, revealed that staff have been documenting Resident 56's May 2024, June 2024, July 2024, and August 2024 TARs incorrectly and they would expect them to follow the physician's order for documentation. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 21 residents reviewed (Residents 19, 20, and 27). Findings include: Review of Resident 19's clinical record revealed diagnoses that included atrial fibrillation (irregular heart beat) and congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Observation on [DATE], at 10:19 AM, revealed a monitor for a pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) was present on Resident 19's bedside stand. Review of Resident 19's current orders revealed an order to make sure her [NAME] (transmitter that reads and sends data from an implanted device to the doctor or clinic without having to visit the office) was plugged in and operating every shift for her pacemaker check, starting [DATE]. Review of Resident 19's current care plan revealed a focus area for decreased cardiac output, which included interventions of pacemaker checks as ordered, and monitor [NAME] as ordered, but failed to include any safety interventions associated with the presence of the pacemaker. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE], at 9:54 AM, the NHA indicated that it would be a good idea to have the safety measures care planned, but she would expect staff to use their professional judgement when they noted the presence of a cardiac pacemaker. During a follow-up interview with the NHA and DON on [DATE], at 12:19 PM, the NHA confirmed that Resident 19's care plan had been revised and confirmed that she would expect pacemaker safety precautions to be included in the care plan. Review of Resident 20's clinical record revealed diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone) and chronic kidney disease (CKD - when the kidneys have become damaged and cannot filter blood the way they should). Review of Resident 20's current active physician orders revealed an order for Full Code, with a revision date of [DATE]. Review of Resident 20's POLST (Pennsylvania Orders for Life-Sustaining Treatment) form, completed on [DATE], revealed Resident 20 wishes to receive CPR (cardiopulmonary resuscitation) and full treatment. Review of Resident 20's current care plan revealed a focus area for Resident wishes to remain a DNR (do not resuscitate) status will be upheld at all times, with an initiation date of [DATE], and a revision date of [DATE]. Documentation provided on [DATE], at 1:46 PM, by the NHA revealed that Resident 20's care plan was updated to reflect that Resident 20 wishes to remain a full code status. Interview with the NHA and DON on [DATE], at 9:58 AM, revealed that they would expect Resident 20's care plan to match their physician orders. Review of Resident 27's clinical record revealed diagnoses that included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), a stage 3 pressure ulcer (a full-thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed), and the presence of an automatic (implanted) cardiac defibrillator (a pacemaker-an artificial device for stimulating the heart muscle and regulating its contractions). Observation of Resident 27 on [DATE], at 10:33 AM, revealed a monitor for a pacemaker at the bedside. Review of Resident 27's clinical record revealed that the Resident developed a diabetic ulcer on [DATE], and that the diabetic ulcer was reclassified as a stage 3 pressure ulcer on [DATE]. Review of Resident 27's care plan revealed an active care plan focus for diabetic ulcer of the left foot, dated [DATE]. Further review of the care plan failed to identify a care plan focus for their stage 3 pressure ulcer. During an interview with the NHA and DON on [DATE], at 9:39 AM, the NHA confirmed that Resident 27's care plan should have been revised when the change in the wound occurred. Further review of Resident 27's care plan revealed a care plan focus for altered cardiovascular status, which included interventions for the presence of an implanted pacemaker and pacemaker checks as ordered, with an initiated date of [DATE], but failed to include any safety interventions associated with the presence of the pacemaker. During an interview with the NHA and the DON on [DATE], at 9:54 AM, the NHA indicated that it would be a good idea to have the safety measures care planned, but she would expect staff to use their professional judgement when they noted that Resident 27 had a pacemaker. During a follow-up interview with the NHA and DON on [DATE], at 12:19 PM, the NHA confirmed that Resident 27's care plan had been revised and confirmed that she would expect pacemaker safety precautions to be included in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 21 residents reviewed (Residents 20, 27, 29, 49, and 56). Findings Include: Review of Resident 20's clinical record revealed diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone) and chronic kidney disease (CKD - when the kidneys have become damaged and cannot filter blood the way they should). Review of Resident 20's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated June 14, 2024, revealed in Section H. Bladder and Bowel, H0100. Appliances, A. Indwelling catheter, that Resident 20 had a catheter while a Resident during the previous 14 days. Review of Resident 20's clinical record failed to reveal any evidence of Resident 20 having a catheter while a Resident during the 14 days prior to the June 14, 2024, MDS. Interview with the Nursing Home Administrator (NHA) on August 6, 2024, at 1:40 PM, revealed that the MDS completed on June 14, 2024, was marked in error and should not have been coded to reveal that Resident 20 had a catheter while a Resident during the previous 14 days. Review of Resident 27's clinical record revealed diagnoses that included depression, congestive heart failure (CHF - disease process of the heart that results in decreased ability of the heart to pump blood through the body), presence of an automatic (implanted) cardiac defibrillator (a pacemaker-an artificial device for stimulating the heart muscle and regulating its contractions), and history of diabetic ulcer. Review of Resident 27's quarterly MDS dated [DATE], revealed in Section I. Diagnoses that the Resident was not coded as having heart failure or depression, but were coded in Section N. Medications as receiving medications for these diagnoses. Review of Resident 27's quarterly MDS dated [DATE], revealed in Section I. Diagnoses that the Resident was not coded as having heart failure or depression, but were coded in Section N. Medications as receiving medications for these diagnoses. Review of Resident 27's Significant Change MDS dated [DATE], in Section I. Diagnoses, Resident 27 was not coded as having an automatic (implanted) cardiac defibrillator or depression but was coded in Section N. Medications as receiving medication to treat their depression. Review of Resident 27's modified quarterly MDS dated [DATE], revealed in Section I. Diagnoses that Resident 27 was not coded as having heart failure or depression. In addition, in Section M. Skin Conditions at question M1040. Other Ulcers, Wounds and Skin Problems, Resident 27 was not coded as having a diabetic foot ulcer. Resident 27 was coded in Section N. Medications as receiving medication to treat their heart failure and depression. Review of Resident 27's quarterly MDS dated [DATE], revealed in Section I. Diagnoses that Resident 27 was not coded as having heart failure or depression. In addition, in Section M. Skin Conditions at question M1040. Other Ulcers, Wounds and Skin Problems, Resident 27 was not coded as having a diabetic foot ulcer. Resident 27 was coded in Section N. Medications as receiving medication to treat their heart failure and depression. Review of Resident 27's clinical record revealed that the Resident was identified as having a diabetic ulcer on June 13, 2024, and continued to have the diabetic ulcer until it was reclassified as a pressure ulcer on July 11, 2024. During an interview with the NHA and Director of Nursing (DON) on August 8, 2024, at 12:23 PM, the NHA confirmed that all Resident 27's MDSs were coded in error, and that she would expect MDSs to be coded to represent an accurate reflection of the resident's status at the time the assessment was completed. Review of Resident 29's clinical record revealed diagnoses that included spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control) and chronic kidney disease stage 4 (when the kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood). Review of Resident 29's May 23, 2024, quarterly MDS revealed that the assessment was coded to indicate that she received an anticoagulant medication (blood thinner) during the look back period (seven days prior to the assessment date). Review of Resident 29's May 2024 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) failed to reveal that Resident 29 had any orders for, or received any anticoagulant medications during the month. In email correspondence received from the NHA on August 6, 2024, at 1:24 PM, she confirmed that Resident 29's May 23, 2024, MDS assessment was coded in error. Review of Resident 49's clinical record revealed diagnoses that included nephritis (a condition in which the tissues in the kidney become inflamed and have problems filtering waste from the blood) and chronic kidney disease stage 4. Review of Resident 49's quarterly MDS dated [DATE], revealed in Section O0110. Special Treatments, Procedures, and Programs, J1. Dialysis, that Resident 49 received dialysis while a resident during the previous 14 days. Review of Resident 49's electronic medical record failed to reveal any instance of Resident 49 receiving dialysis while a resident during the 14 days prior to the July 25, 2024, MDS. Interview with the DON on August 8, 2024, at 9:35 AM, revealed that the MDS completed on July 25, 2024, should have not been coded to reveal that Resident 49 received dialysis while a resident during the previous 14 days. Review of Resident 56's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of Resident 56's quarterly MDS dated [DATE], as well as their quarterly MD dated June 2, 2024, revealed in Section N. Medications, N0415. High-Risk Drug Classes: Use and Indication, that Resident 56 was prescribed antianxiety medications and antidepressant medications while a resident during the previous 14 days. Further review of Resident 56's quarterly MDS dated [DATE], as well as their quarterly MDS dated [DATE], revealed in Section I. Active Diagnosis, Psychiatric/Mood Disorder, that anxiety disorder was marked No, as well as depression (other than bipolar) was marked no, indicating Resident 56 does not have a diagnosis of anxiety or depression while a resident during the previous 14 days. Interview with the NHA on August 8, 2024, at 12:13 PM, she confirmed that Resident 56's quarterly MDS's on March 6, 2024, and June 2, 2024, were errors and should have been coded to reflect Resident 56 has an anxiety and depression diagnosis. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen in two of two kitchenettes, on tray service line, and in one of two ice machines (Tulip kitchenette). Findings include: Review of facility policy, titled Labeling & Dating, dated January 2016, revealed All foods will be appropriately wrapped, labeled and dated based on food storage guidelines. Appropriate storage temperatures and food rotation procedures are followed. All foods are labeled, dated, and securely covered and use-by-dates are monitored and followed. Review of facility policy, titled Receiving & Storage, dated January 2016, revealed 5. All items are dated when received to ensure correct product rotation and 6. Products must be checked to detect unacceptable items, i.e. dented, swollen or rusted cans Review of facility policy, titled Outside Food, dated March 2018, revealed that any food that is brought in for residents by visitors will be labeled, dated, and discarded according to procedure; 2. Labels should include the resident name, room number, date the food was brought in, date it was opened and the date it should be discarded by. Tour of the kitchen with Employee 4 (Director of Dining Services) on August 5, 2024, at 9:46 AM, revealed the following concerns: 1) The walk-in production cooler contained a large plastic container of toasted sesame dressing and mayonnaise that were not dated. An immediate interview with Employee 4 revealed that the items should have been dated when opened and should be discarded if not used in within six months of the open date. 2) The walk-in freezer contained a bag of French fries, a bag of frozen fish filets, and a bag of garlic bread that were not sealed closed, a package of waffles (not in a shipment case) that had not been opened but had no dates indicated on the packaging, and a bag of frozen mixed vegetables (not in a shipment case) that had not been opened but had no dates indicated on the packaging. An immediate interview with Employee 4 revealed that they go by the shipment date on the label, which is located on the case, to determine expiration dates, and confirmed that there was no date on the waffles or mixed vegetables as they were no longer contained in the shipment case. Employee 4 also confirmed that the fries, fish, and garlic bread were not sealed closed. 3) The dry storage room contained an opened case of oatmeal creme pie snack cakes with no shipment date noted on the case; an open package of spiral noodles, open package of spaghetti noodles, and an open bottle of barbecue sauce that had no open dates indicated. An immediate interview with Employee 4 indicated that they do not date the boxes of snack cakes. The facility goes by the shipment date on the case and that they are discarded if not used in within six months of the shipment date unless there is use by date specifically indicated on the packaging by the manufacturer. Employee 4 confirmed that the case of oatmeal creme pie snack cakes had no shipment label and stated, it vanished. Employee 4 also confirmed that the pasta noodles and barbecue sauce were not dated with an open date. 4) The produce cooler contained a plastic manufacturer container of strawberries with gray fuzz noted on the strawberries. None of the produce was noted to be dated. An immediate interview with Employee 4 revealed that they do not date produce and that they go by appearance of the fruit and vegetables to determine when it should be discarded. 5) The canned goods rack contained a dented can of apple pie filling and fruit cocktail, and butterscotch pudding; and the banana pudding, diced apples, and caramel topping cans contained no dates. An immediate interview with Employee 4 revealed that the dented cans should not have been placed on the rack when received dented. In addition, Employee 4 confirmed that there were no dates on banana pudding, diced apples, and caramel topping. 6) In the prep area there was an open container of molasses that indicated by the manufacturer to use by May 4, 2024; an open container of mustard and soy sauce with no dates noted; and a box of corn starch that was not sealed closed. Employee 4 confirmed that the molasses should have discarded, the mustard and soy sauce should have been dated, and that the corn starch should have been sealed closed. Observation of the cooking area revealed a metal shelving unit that had 19 servings ladles stored with scoop side up hanging off the side of the shelf near a passageway through the kitchen. Employee 4 offered no information as to why these would be stored in this manner. During an interview with Employee 4 on August 5, 2024, at 10:14 AM, Employee 4 confirmed that he would expect items to be labeled, dated, and stored properly. Observation of the [NAME] Unit Kitchenette on August 5, 2024, at 10:20 AM, revealed in the cupboard an open plastic container of ketchup and mustard that were not dated with an opened date. In the refrigerator, there was a clear plastic manufacturer container of hummus and a clear plastic manufacturer container of cherry tomatoes with no name or date noted. Observation of tray line in the Tulip kitchenette on August 6, 2024, at 11:56 AM, revealed that Employee 1 was serving food on the tray line with clear gloves present on both hands. Employee 1 left the tray line and used their right gloved hand to open the refrigerator door handle, and then used both of their gloved hands to retrieve a package of tortilla wraps and a chilled plate. Employee 1 proceeded to go to the counter, open the package of tortillas, remove one, fill it with a meat salad, used both of their gloved hands to roll the wrap and hold it while cutting it in half, and then Employee 1 placed the wrap on the plate and handed it to another employee to serve. Employee 1 then removed their gloves and applied a new pair of gloves. Employee 1 was then witnessed to again leave the tray line and, with their right gloved hand, retrieved a chilled plate and took it to Employee 5. Employee 1 then returned to the tray line and continued to plate food. Employee 1 used their left gloved hand to move the mixed vegetables over on the plate that they had placed too close to the edge of the plate with the scoop. Employee 1 was then observed to place a scoop of chopped meat onto a plate. Employee 1 then realized that they had placed the meat on the wrong type of plate. Employee 1 then used her right gloved hand, which they had previously used to touch the refrigerator door handle, and scraped the meat off the plate onto the correct plate. During an interview with Employee 1 on August 6, 2024, at approximately 12:15 PM, Employee 1 confirmed that they had touched the door handle of the refrigerator and then touched food that was served to residents without changing their gloves. Observation of the Tulip kitchenette on August 7, 2024, at 10:16 AM, revealed a plastic storage container of brown sugar that had a small scoop stored inside of the container. The ice machine had a serving scoop stored inside of the ice machine on the right-hand side in a metal type rack. An employee dressed in scrubs was observed to come in and retrieve ice from the machine and place it in a clear water pitcher. This employee was not observed to have washed their hands prior to using the scoop in the ice machine. In addition, it was noted that there were two stacks of divided plates and lip plates on the counter with the service side being upright; a large plastic bin of coffee cups sitting out on the counter with approximately 20 cups sitting with the service side being upright; and there were approximately seven stacks of plate domes on the counter with the service side being upright. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 7, 2024, at 11:06 AM, all observations were shared. The NHA confirmed that she would expect items to be labeled, dated, and stored properly and that food should be served in a sanitary manner. Review of facility provided Refrigerator Temperature Log indicated maintain refrigerator temperature at 40 degrees Fahrenheit or below and to complete the corrective action column if temperatures are not in proper ranges. Review of recorded temperatures for the Tulip dining room kitchenette refrigerator for June 2024, revealed the following temperature concerns: 1) June 3, at 4:30 PM, the temperature was logged as 44 and no information was included in the corrective action/comments column; 2) June 4, at 4:30 PM, the temperature was logged as 42 and no information was included in the corrective action/comment's column; 3) June 5, at 4:30 PM, the temperature was logged as 45 and no information was included in the corrective action/comment's column; 4) June 9, at 4:45 PM, the temperature was logged as 45 and in the corrective action column it stated staff restocked reach-in; 5) June 11, at 11:45 AM, the temperature was logged as 47 and in the corrective action column it stated door opened; 6) June 12, at 11:36 AM, the temperature was logged as 48 and in the corrective action column it stated refrigerator defrosting; 7) June 14, at 11:18 AM, the temperature was logged as 50 and in the corrective action column it stated door opened; 8) June 15, at 11:30 AM, the temperature was logged as 50 and in the corrective action column it stated door opened; 9) June 16, at 11:20 AM, the temperature was logged as 49 and in the corrective action column it stated door opened notified maintenance; 10) June 18, at 11:50 AM, the temperature was logged as 43 and no information was included in the corrective action/comments column; 11) June 22, at 5:40 PM, the temperature was logged as 43 and no information was included in the corrective action/comments column; and 12) June 23, at 5:35 PM, the temperature was logged as 43 and no information was included in the corrective action/comments column. During an interview with the NHA and DON on August 8, 2024, at 12:22 PM, the NHA indicated that she had spoken to Employee 5 and that they indicated that if staff were to check a refrigerator temperature and it was noted to be high, that they would recheck it in an hour and then, if it was still elevated, they would notify maintenance. NHA confirmed that they had no additional information to provide and that she would expect staff to have followed the process and food would be stored at appropriate temperatures. 28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, record review, and staff interview, it was determined the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for one of 21 residents reviewed (Resident 56). Findings include: Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last revised in March 2022, revealed that the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident 56's clinical record revealed diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of Resident 56's clinical record revealed an active physician's order for Haloperidol 0.5 milliliters orally two times a day for terminal agitation, with an active date of May 2, 2024. Review of Resident 56's current comprehensive person-centered care plan failed to reveal a care plan focus area or intervention area for their use of an antipsychotic medication. During an interview with the Nursing Home Administrator on August 8, 2024, at 12:13 PM, revealed that Resident 56's care plan now included a focus area for their use of an antipsychotic medication, and that she would have been expected the care plan to have been implemented prior to this day. 28 Pa. Code 211.11 (d) Resident care plan

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing for one of two residents reviewed (Resident 42). Findings include: Review of Resident 42's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic atrial fibrillation (when the abnormal heart rhythm lasts for more than a week). Review of Resident 42's July 2024 TAR (Treatment Administration Record) revealed an order for mid back wound: cleanse with normal saline, allow to dry, apply skin prep to peri wound, apply medi honey to a piece of calcium alginate and place directly to wound bed, secure with foam dressing every day shift for wound care, with a start date of July 26, 2024. Further review of Resident 42's July 2024 TAR revealed that the treatment for the mid back wound was blank on July 27, 30, and 31, 2024, indicating that it was not completed on those days. Review of Resident 42's July 2024 TAR also revealed an order for right back wound: cleanse with normal saline, allow to dry, apply skin prep to peri wound, apply double layer of xeroform, secure with dry sterile dressing, every day shift every 2 days for wound care, with a start date of July 25, 2024. Further review of Resident 42's July 2024 TAR revealed that the treatment for the right back wound was blank on July 27 and 31, 2024, indicating that it was not completed on those days. Review of Resident 42's clinical record revealed no progress notes indicating why the wound treatment was not completed for their mid back wound on July 27, 30, and 31, 2024, and for their right back wound on July 27 and 31, 2024. Interview with the Nursing Home Administrator and the Director of Nursing on August 8, 2024, at 9:59 AM, revealed they would expect staff to document on the TAR once the treatment is completed, and to write a progress note in their clinical record documenting if the resident is refusing care. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for two of two residents reviewed (Residents 19 and 27). Findings include: Review of facility policy, titled Adaptive Feeding Devices, dated January 2016, revealed, Adaptive feeding equipment will be provided to residents to enhance resident independence and comfort . The Food & Nutrition Services Department will store the adaptive equipment and provide to resident for use during meals and snacks. Review of Resident 19's clinical record revealed diagnoses that included atrial fibrillation (irregular heart beat) and GERD (gastroesophageal reflux disease - digestive disease where the muscle rings between the stomach and esophagus become weak or relax inappropriately allowing the stomach's contents to flow up into the esophagus). Review of Resident 19's current orders revealed an order for adaptive equipment during meals, including dycem (non-slip mat) under her plate, starting April 1, 2024. Review of Resident 19's current care plan revealed that she had a self-care performance deficit related to confusion, general weakness, immobility, and cognitive impairment, and that she required adaptive equipment while eating including dycem under her plate at the table. Observation on August 5, 2024, at 12:09 PM, revealed Resident 19 eating her meal. No dycem was present under her plate. Several times her plate slid when she took a scoop of food, causing her to reposition it before taking another bite. Observation of Resident 19's meal ticket at that time revealed it was notated that she should have dycem under her plate during meals. During an interview with Employee 3 (Nurse Aide) at the time of observation, she stated that she inquired about Resident 19's dycem and was told by dietary staff that they did not have any on hand in the dining room, but that someone would go get it. Resident 19 was provided with a piece of dycem at 12:19 PM. During an interview with the Nursing Home Administrator (NHA) on August 8, 2024, at 12:20 PM, she revealed the expectation that Resident 19 should have had all required adaptive equipment. Review of Resident 27's clinical record revealed diagnoses that included Parkinson's disease (a long-term degenerative disorder of the central nervous system that mainly affects the motor system) and muscle weakness. Review of Resident 27's physician orders revealed an order for a Kennedy cup dated March 3, 2024. Review of Resident 27's care plan revealed a care plan focus for being at risk for alterations in nutrition and hydration and at risk for aspiration, with an intervention to provide adaptive equipment as ordered, with a revision date of July 1, 2024. Observation of Resident 27 at lunch on August 5, 2024, at 12:18 PM, revealed that the Resident had a two handled sippy cup with a straw. During an interview with Employee 2 on August 5, 2024, at 12:19 PM, Employee 2 indicated that Resident 27 did not have a Kennedy cup because they are all upstairs. Observation of Resident 27 at lunch on August 7, 2024, at 12:12 PM, revealed that the Resident had a two handled sippy cup with a straw and no Kennedy cup. Observation of Resident 27 at breakfast on August 8, 2024, at 9:00 AM, revealed that the Resident had a two handled sippy cup with a straw and no Kennedy cup. During an interview with the NHA and Director of Nursing on August 8, 2024, at 9:40 AM, the NHA confirmed that she would expect residents to receive their adaptive equipment as ordered. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of select facility forms, and staff interviews, it was determined that the facility failed to ensure that six residents have the right to a dignified existence during meal service for one of one meals observed (Residents 39, 42, 47, 51, 213, and 219). Findings include: Observation of tray line meal service in the Skilled Dining Room on October 3, 2023, at 12:30 PM, revealed Resident 213 was served pureed food on a divided plate, and the entree portion of the meal was served on the upper left corner of the divided plate. Further observation in the Skilled Dining Room during lunch meal service on October 3, 2023, at 12:39 PM, revealed that six residents (Residents 39, 42, 47, 51, 213, and 219) on pureed diet texture were served meals on divided plates. Review of select facility forms provided on October 5, 2023, at 10:14 AM, revealed Residents 39, 42, 47, 51, 213, and 219 were ordered pureed diet textures and not ordered divided plates. Interview with Employee 2 (Dietary Manager) on October 3, 2023, at 12:51 PM, revealed nursing staff recommended all residents on pureed diets to be served on divided plates. Interview with the Nursing Home Administrator (NHA) on October 4, 2023, at 12:31 PM, revealed there were no meetings of formal decisions with management regarding pureed diet textures served on divided plates, and she would not expect that to occur. During a follow-up interview with the NHA on October 5, 2023, at 11:33 AM, revealed she had a meeting with dietary staff to serve residents on pureed diet texture on regular plates, unless adaptive equipment is ordered and indicated. 28 Pa Code 201.29(d) Resident Rights

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to post the required information on how to file a grievance, failed to post the grievance policy, failed to provide the right to file grievances anonymously, and failed to post the name of the Grievance Official for residents to file a grievance orally (meaning spoken) for three out of three resident units in the facility. Findings include: Review of facility policy, titled Grievance/Complaint Process, last revised September 20, 2023, revealed section titled Procedure/Process, stated, .A copy of our grievance/complaint procedures is posted in prominent locations throughout the facility and provided to residents, representatives, family members and sponsors as requested. The policy failed to include how to file a grievance anonymously, and failed to identify who the Grievance Official is and their contact information including their name, business address, and phone number. Observations of all resident areas on October 3, 2023, at 10:00 AM; October 4, 2023, at 1:00 PM; and October 5, 2023, at 9:15 AM, revealed the facility failed to post written information on the grievance policy and procedure, and failed to post information that identified the facility's Grievance Official, the Grievance Official's business mailing and email address, and phone number. During an interview with the Nursing Home Administrator (NHA) on October 5, 2023, at 11:48 AM, she confirmed that they go over the grievance policy during admission, and there is a mailbox outside of the Social Workers office to put the forms in if the residents would choose to file anonymously. The NHA confirmed they will post the required information, including information on who the grievance official is and the written grievance policy and procedure. 28 Pa Code 201.18(b)(2)(3)Management 28 Pa code 201.29(a) Resident rights

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 16 residents reviewed (Resident 42 and Resident 47). Findings Include: Review of Resident 42's clinical record revealed diagnoses that included anxiety disorder (persistent and excessive worry that interferes with daily activities) and dysphasia (swallowing difficulties). Review of Resident 42's physician's orders revealed an order dated July 20, 2023, for hospice evaluation and treatment. Review of an electronic mail document provided by the Nursing Home Administrator (NHA) revealed confirmation from the Social Worker 1, that Resident 42 has been admitted to Hospice effective July 20, 2023, due to protein calorie malnutrition. Review of Resident 42's significant change MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated July 31, 2023, revealed that Section O0100k. Hospice Care was not checked, indicating that Resident 42 had not received hospice care in the previous 14 days, while a Resident or while not a Resident. Interview with the NHA on October 5, 2023, at 11:07 AM, revealed that Resident 42 had received hospice services during the 14-day look-back prior to the July 31, 2023, MDS and should have been marked accordingly. Review of Resident 47's clinical record revealed diagnoses that included cerebral infarction (stroke - damage to the brain from interruption of its blood supply), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and depression. Review of Resident 47's physician's orders revealed orders for quetiapine (Seroquel-an antipsychotic medication) 25 milligram tablet, give one tablet daily at bedtime for dementia with delusions, hold for increased lethargy, dated September 30, 2023; trazodone (an antidepressant) 50 milligram tablet give one tablet daily at bedtime, dated May 19, 2023; and duloxetine (Cymbalta-an antidepressant) 60 milligram capsule delayed release daily, dated April 28, 2023. Review of Resident 47's order history revealed that they had been on quetiapine since April 17, 2023; trazodone since May 17, 2023; and duloxetine since April 17, 2023. Review of Resident 47's Admission MDS with the assessment reference date (last day of the assessment period) of April 21, 2023, failed to include in Section I: Active Diagnoses the diagnosis of depression. Review of Resident 47's physician's progress notes revealed a note dated April 26, 2023, which indicated the presence of right sided weakness and continue with current dose of Seroquel and Cymbalta. Review of Resident 47's clinical record revealed a form, titled Note to Attending Physician/Prescriber, completed by the pharmacist requesting the ongoing use of quetiapine be evaluated, dated April 19, 2023; on which the physician documented benefits were greater than risks; no change on April 21, 2023. Review of Resident 47's Significant Change MDS with the assessment reference date of May 27, 2023, failed to include in Section I: Active Diagnoses the diagnosis of depression. Further review of Resident 47's Significant Change MDS with the assessment reference date of May 27, 2023, indicated in Section N: Medications at subsection N0450 Antipsychotic Medication Review, that the physician had not documented that a gradual dose reduction was clinically contraindicated. Further review of Resident 47's form, titled Note to Attending Physician/Prescriber, completed by the pharmacist requesting the ongoing use of two antidepressants be evaluated dated June 3, 2023; on which the physician documented no change due to ongoing indicated to continue current doses due to ongoing behavior on June 7, 2023. Review of Resident 47's physician progress notes revealed a note dated June 7, 2023, in which the physician documented diagnoses of left sided weakness, dementia, and depression; to continue current medications; and that at the present time benefit seems to outweigh any potential risks. Review of Resident 47's Quarterly MDS with the assessment reference date of August 25, 2023, 2023, failed to include in Section I: Active Diagnoses the diagnosis of hemiplegia (paralysis of one side of body)/hemiparesis (muscle weakness on one side of the body) or depression. Further review of Resident 47's Quarterly MDS with the assessment reference date of August 25, 2023, indicated in Section N: Medications at subsection N0450 Antipsychotic Medication Review that the physician had not documented that a gradual dose reduction was clinically contraindicated. During an interview with Employee 1 (Registered Nurse Assessment Coordinator) on October 4, 2023, at 1:31 PM, Employee 1 indicated that the MDSs were coded inaccurately in Section N. Medications because there was supporting physician documentation that a gradual dose reduction was clinically contraindicated. During a follow-up interview with Employee 1 on October 5, 2023, at 11:06 AM, Employee 1 confirmed that hemiplegia/hemiparesis should have been coded on the MDS with the assessment reference date of August 25, 2023, and that depression should have been included as an active diagnosis on all of Resident 47's MDSs. During an interview with the NHA and Director of Nursing on October 5, 2023, at 11:51 AM, the NHA confirmed that she would expect Resident MDSs to be coded accurately. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for one of 19 residents reviewed (Resident 47). Findings include: Review of facility policy, titled Physician's Orders, with a last review date of January 11, 2023, revealed the following: Standard of Care: All physician's orders shall be obtained, transcribed, and administered according to the physician's order; 1) The charge nurse will review the medical records for new orders written by the physician/provider immediately following the physician's visit; 5) The charge nurse/ nurse manager/ designee shall be responsible for transcribing orders; and 11) It is the responsibility of the nurse receiving this order to follow through with documentation and transcription to ensure that orders are changed and administered in a timely and accurate manner. Review of Resident 47's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), peptic ulcer disease (a sore that develops on the lining of the esophagus, stomach, or small intestine), systolic congestive heart failure (heart failure that occurs when the left ventricle in the heart cannot pump enough blood), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 47's clinical record revealed a form, titled Note to Attending Physician/Prescriber, dated April 19, 2023, on which the physician documented an order to decrease Protonix (pantoprazole - a medication used to treat high levels of stomach acid or a damaged stomach) to 20 milligrams daily, with a signature date of April 21, 2023. There was additional notation on the form by facility nursing staff indicating the order was completed on April 24, 2023. Review of the order history for Resident 47 confirmed that the entered start date for this order was April 24, 2023, three days after the order was written by the physician. Further review of Resident 47's clinical record revealed a form, titled Note to Attending Physician/Prescriber, dated August 13, 2023, which the physician documented an order to decrease Protonix (pantoprazole- a medication used to treat high levels of stomach acid or a damaged stomach) to 20 milligrams every two days, with a signature date of August 24, 2023. There was additional notation on the form by facility nursing staff indicating the order was completed on September 5, 2023. Review of the order history for Resident 47 confirmed that the entered start date for this order was September 5, 2023, 13 days after the order was written by the physician. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on October 5, 2023, at 1:08 PM, the NHA confirmed that she would expect physician orders to be implemented in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas. Findings include: Review of facility policy, titled Section 11: Sanitation & Infection Control Labeling & Dating, last revised January, 2016, revealed, Policy: All foods will be appropriately wrapped, labeled and dated based on food storage guidelines .Procedure: All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. Review of facility policy, titled Food Safety Management System, last revised [DATE], revealed, liquid pasteurized eggs and egg substitutes have a shelf life of 3 days once opened, dried herbs and opened spices have a shelf life of ,d+[DATE] months, and fresh herbs have a shelf life of one week. Observation of the dry storage area on [DATE], at 9:42 AM, revealed: two trays of individual peanut butter packets not dated; one container of individual jellies not dated; five boxes of cream of wheat not dated; three packages of barley with a use by date of [DATE]; two containers of rice pilaf open and not dated; two packages of tempura batter open and not dated; two containers of maraschino cherries not dated; two packages of cornbread and muffin mix, one open, both not dated; one container of poppy seeds with a use by date of [DATE]; one container of black sesame seeds with a received date of [DATE]; one container of baking powder with a use by date of [DATE]; one container of corn meal with a scoop stored inside; one package of almonds with a use by date of February 20, 2023; and one package of oven ready lasagna with a use by date of February 19, 2023. Interview with Employee 2 (Dietary Manager) on [DATE], at 9:49 AM, revealed foods should be labeled and dated per facility policy. Observation in the main kitchen on [DATE], at 10:00 AM, revealed: one container of chipotle powder with a use by date of [DATE]; one container of dried basil leaves with a use by date of [DATE]; one bin of flour not dated with a scoop inside; one bin of sugar not dated; and nine bowls stored right-side up on a shelf. Observation of the walk-in refrigerator on [DATE], at 10:07 AM, revealed: one package of shredded cheddar cheese open not dated; one pack of turkey bacon not dated; one container of Italian dressing not dated; and one container of dill pickles open and not dated. Observation of the produce walk-in refrigerator on [DATE], at 10:11 AM, revealed: one container of cilantro dated [DATE], with wilted herbs; one bin of white onions not dated; one box of sweet potatoes not dated; two heads of cabbage on a shelf not dated; one open container of broccoli not dated; and two bags of russet potatoes not dated. Observation in walk-in freezer unit on [DATE], at 10:14 AM, revealed: one bag of French bread pizzas not dated, and the bag was open to air; one package of beef roast not dated; two packages of french fries, one open, both not dated; and one pan of biscuits not dated. Observation of the reach-in refrigerator in the main kitchen on [DATE], at 10:17 AM, revealed: one open bag of minced onions not dated, and the onions appeared to be spoiled. Observation during initial tour of the skilled dining area refrigerator on [DATE], at 10:21 AM, revealed: one container of labeled butter packets with a use by date of [DATE], and the container had margarine packets stored inside; and one container of liquid eggs open without an open date. Observation of the ice machine in the skilled dining area on [DATE], at 10:22 AM, revealed a brown substance on the inside door of the ice machine. Further observation of the ice machine revealed there was no air gap between the drain of the ice machine and the floor drain. Observation of the pantry in the skilled dining area on [DATE], at 10:24 AM, revealed: a microwave on the counter that was dirty inside; one bag of corn flakes cereal with a use by date of [DATE]; one bag of ketchup packets not dated; one bag of mustard packets not dated; and one container of mustard and mayonnaise packets not dated. Observation during initial tour of the rehabilitation unit dining area refrigerator on [DATE], at 10:28 AM, revealed: one container of individual butter packets and one container of individual creamer packets not dated. Observation of the ice machine in the rehabilitation unit dining area on [DATE], at 10:29 AM, revealed a black substance on the sides of the inside of the ice machine. Further observation of the ice machine revealed there was no air gap between the drain of the ice machine and the floor drain. Observation of the pantry in the rehabilitation unit dining area on [DATE], at 10:34 AM, revealed: a microwave on the counter that was dirty inside; one container of butter packets on the counter not dated; three granola bars not dated; four packets of salad dressing not dated; one container of saltine crackers not dated; and one container of individual syrup packets not dated. Interview with the Nursing Home Administrator on [DATE], at 12:28 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on review of clinical records, select facility investigation reports, and staff interviews, it was determined that the facility failed to implement safety interventions and staff supervision, to prevent an accident hazard which resulted in a fall with bodily injury ([MEDICAL CONDITION]), for one out of three residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Review of a fall report dated (MONTH) 9, 2019, revealed that Resident 1 was found on the floor in her bedroom. Resident 1 reported pain in her right upper arm and right hip. The resident was sent to the emergency room and was diagnosed with [REDACTED]. The facility's investigation discovered that Nurse Aide (NA) 1 transferred Resident 1 into the bathroom. NA 1 told the resident to ring the call bell when she was finished, and the nurse aide left the room. The resident did not ring the call bell when she was finished and attempted to transfer herself back to her bed and fell . Review of the Resident 1's care plan revealed that she was not be left alone in the bathroom and to wear non-skid footwear. The resident was left alone in the bathroom and was not wearing non-skid footwear at the time of the fall. Review of the care guide (abbreviated care plan that the nurse aides use as a reference) revealed that it did not include the intervention for the resident to not be left alone in the bathroom. During an interview with NA 1 on (MONTH) 12, 2019, at 12:05 PM she confirmed that when she looked at the care guide and the intervention for the resident to not be left alone in the bathroom, was not listed. She also stated that she was unaware that the resident was supposed to wear non-skid footwear. During an interview with the Director of Nursing on (MONTH) 12, 2019, at 11:50 AM she stated that the intervention for the resident not to be left alone in the bathroom was not linked to the care guide and that she fixed that immediately after the fall. She also stated that it was standard of care that residents needed to wear non-skid footwear during transfers and ambulation. During an interview with the Nursing Home Administrator on (MONTH) 13, 2019, at 10:30 AM he confirmed that the nurse aide should have followed the plan of care. The facility failed to implement safety interventions and staff supervision, to prevent an accident hazard which resulted in a fall with bodily injury ([MEDICAL CONDITION]) for Resident 1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 2/28/19, 10/11/18. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 2/28/19, 12/19/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 2/28/19, 10/26/17. 28 Pa. 211.11(d) Resident care plan. Previously cited 10/26/17. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 2/28/19, 10/11/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/28/19, 10/11/18, 10/26/17.

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure that safe transfer techniques were used to prevent a resident accident that resulted in harm for one of three residents reviewed (Resident 1), who fell out of a sling that disconnected during a transfer with a Hoyer (mechanical lift used to transfer residents) lift and sustained a large lump to the neck and pupils became fixed and pinpoint. Findings include: Review of Resident 1's clinical record revealed an admitted (MONTH) 13, (YEAR), and an admitting [DIAGNOSES REDACTED]. Review of Resident 1's quarterly Minimum Data Set assessment (MDS - an assessment of a resident's functional capabilities and helps nursing staff identify health care needs) dated (MONTH) 13, 2019, revealed that Resident 1's transfer status was total dependence with full staff performance every time and a two-person physical assist. Review of documentation provided by the facility on (MONTH) 18, 2019, at 7:00 AM revealed that Resident 1 was found lying across the legs of the lift, with her neck on one leg and her lower legs on the other. Nurse Aide (NA) 1 and NA 2 stated the resident fell out of the lift. There was a large lump to the back of Resident 1's neck and a skin tear to her left hand. The resident showed no signs or symptoms of pain initially but was showing signs and symptoms of pain such as whimpering when staff put her to bed. Review of the neurological assessment (an assessment of the nervous system responses, especially reflexes, to determine whether the nervous system is impaired) which began on (MONTH) 18, 2019 at the time of the fall, revealed Resident 1's pupils were non-reactive to light, fixed and pinpoint (all of which are abnormal, normal pupil are equal, round, reactive to light and 2 to 3 millimeters in diameter). Review of Resident 1's Care Guide (used by nurse aides to inform them of the care a resident needs) dated (MONTH) 13, (YEAR), revealed Resident 1 was non-ambulatory and required the use of a Hoyer lift and a medium sized sling for transfers. Review of a witness statement dated (MONTH) 18, 2019, at 8:45 a.m. written by NA 1 indicated she placed the lift pad (sling) under the resident and hooked it up to the Hoyer lift. NA 2 came into the room to help with the transfer. NA 1 was working the Hoyer lift, as Resident 1 was lifted off the bed and being pulled and lifted away from the bed and positioned to put her in the chair, Resident 1 fell out of the lift pad (sling) which came off the lift. Review of NA 2's witness statement not dated, revealed that NA 1 had a hold of Resident 1 guiding her into place before lowering her into the Broda (type of reclining chair) chair. As NA 1 tried to turn Resident 1 in the lift she swayed a little while trying to clear the mat and the lift sling slipped off the Hoyer lift and Resident 1 fell to the floor. Review of NA 2's Evaluation of Mechanical Lift revealed that training was provided on (MONTH) 16, (YEAR). NA 1 was provided mechanical lift training on (MONTH) 27, (YEAR). Review of a physician progress notes [REDACTED]. Review of a physician progress notes [REDACTED]. Review of a progress note dated (MONTH) 18, 2019, at 12:26 PM by Licensed Practical Nurse (LPN) 1 revealed it was reported to LPN 1 that Resident 1 was on neuro checks (neurological evaluations) and the resident's BP (blood pressure) has been up and down. PRN (as needed) [MEDICATION NAME] was administered and the resident was found to be awake. Resident 1 responded to greeting with non-sensical sounds. There was a baseball sized bump on the base of Resident 1's skull that was very soft and fluid filled. The pupils were pin point and fixed, BP was 197/105 (normal is 120/80), POX (pulse oxygen - non-evasive procedure that determine the percentage of oxygen in the blood) was 84% on room air (normal is 92% or greater). Resident 1 was placed on two liters per minute of oxygen. Further review of the progress note revealed that the response to the question - has the patient's condition declined since the last visit? - which was (MONTH) 15, 2019, the response by LPN 1 was Yes. Review of documentation provided by the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on (MONTH) 21, 2019, revealed an immediate in-service for Hoyer Lift safety to all licensed and non-licensed staff related to the mechanical lift policy training was done on (MONTH) 18, 2019 and (MONTH) 19, 2019, sign in sheets were also provided with the same dates of staff attendance. A safety check was done on the Hoyer lift by Maintenance and nothing was found to be working improperly. An interview with the NHA and the DON on (MONTH) 28, 2019, at 1:00 PM revealed that both Nurse Aides were trained on the use of the Hoyer lift prior to the fall. The facility failed to ensure that safe transfer techniques were used to prevent a resident accident that resulted in harm for Resident 1 who fell out of a sling that came off during a transfer with a Hoyer lift and sustained a large lump to the neck and her pupils became fixed and pinpoint. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 10/11/18. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 12/19/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/26/17. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 10/11/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/11/18, 10/26/17.

Based on record review, policy review and interview, it was determined that the facility failed to implement a comprehensive plan of care by an interdisciplinary team and failed to review and revise the care plan as necessary to meet the needs of one of 16 residents reviewed (Resident R1). Findings include: Review of the, Mechanical Lift Policy, last reviewed February 2016, revealed that all residents will be assessed on admission for the need of a mechanical lift device. A physician's order will be written indicating the type of lift and the size of the sling to be used. Lift type and sling size will be written in the residents' plan of care. The residents' need for, and type of lift/sling size will be reviewed and updated by the Registered Nurse Supervisor, Charge Nurse and/or therapy department at least quarterly (every three months) or with any significant change in resident status. Review of the clinical record for Resident 1 on September 6, 2016, at 3:00 p.m. revealed [DIAGNOSES REDACTED]. Resident 1's admission Minimum Data Set assessment (MDS - a periodic assessment to identify a resident's physical, mental, and psychosocial needs) dated April 22, 2016, revealed a BIMS score (Brief Interview of Mental Status -an interview conducted with the resident to determine cognitive status) was eight out of 15, indicating her cognitive status was moderately impaired. Review of Resident 1's Discharge Occupational Therapy Notes (last note written by the therapist for the resident's last therapy session) dated May 20, 2016, revealed she requires moderate assistance with two persons for toileting. Review of Resident 1's Discharge Physical Therapy Notes dated May 20, 2016, revealed she requires a sit to stand lift (mechanical lift that uses a safety sling around the back of the resident and has grab bars for the resident to grab onto to transfer from a sitting position to a standing position between a bed and a chair or other similar resting places for transfers, if needed) transferred with moderate assist and verbal cues (half the time verbally talking the resident through the transfer process). Review of Resident 1's Activity of Daily Living Care Plan (ADL-care plan that addresses normal activities performed daily) dated June 6, 2016, stated that Resident 1 required a two person transfer, and stated that she may use a mechanical lift (devices that utilize a sling to transfer from one location to the other) but failed to specify a sling lift or a stand lift. Review of the facility lifts revealed that they have two types of mechanical lifts. The sling lift also known as a Hoyer lift (brand name of full body sling lift) is used to lift the entire body into midair on a sling and transfer the resident to a chair or back to bed or other similar resting place. The stand lift mechanical lift that uses a safety sling around the back of the resident and has grab bars for the resident to grab onto as he/she transfer from a sitting position to a standing position between a bed and a chair or other similar resting places for transfers, if needed. Review of the Mechanical Lift policy dated February 2016, included both the Mechanical Standing Lift and the Mechanical Full Body Lift (aka Hoyer Lift). Within the ADL Care Plan, a Restorative Nursing Program (RNP-actions to be taken by a Nurse Aide to maintain the functional gains made in physical, occupational and speech therapy) for Resident 1 with the following goal: resident will be able to perform sit to stand transfer using grab bar with moderate assist and maintain standing 30-60 seconds at a time. The first action to meet this goal included the following: to have resident pull up from grab bar to stand with moderate assist and have her maintain standing 30-60 seconds at a time. The second action stated that Resident 1's knees have a tendency to bend so blocking her knees will keep Resident 1 standing longer and more stable. Review of the Hall Sheet (a form that provides information on residents in a specific hall and residents transfer status dated as developed May 16, 2016) revealed Resident 1 was to have two persons assist her to transfer or to use a Hoyer Lift. Review of Resident 1's Fall Care Plan for Transfers/Toileting dated June 6, 2016, and effective through July 24, 2016, revealed that Resident 1 was to be assisted with toileting as needed. The Fall Care Plan was revised July 25, 2016, with a statement that staff education was provided to use two person assist to transfer Resident 1. The Fall Care Plan was revised on July 27, 2016, stating that staff education was provided to have the staff remind Resident 1 not to stand until there was assistance. Review of the clinical record nursing notes dated July 28, 2016, revealed that Resident 1 was an extensive assist of two persons for transfers. Review of the, Resident Care Sheet dated September 1, 2016 stated that Resident 1 was a two person assist for transfers and required a Hoyer Lift for transfers. During an interview with Licensed Practical Nurse 1, LPN 1, on September 8, 2016, at 2:41 p.m. when she was shown Resident 1's care plan, she revealed it was the first time she had viewed Resident 1's care plan. When LPN 1 read the RNP section of the care plan, she stated Resident 1 was able to have a stand lift based on the RNP. During the interview with LPN 1 on September 8, 2016, at 2:41 p.m. regarding the incident with Resident 1 that occurred June 8, 2016, she indicated that on June 8, 2016, she was performing her evening medication pass (administering medications) in the hallway outside of Resident 1's room, when she heard someone call out help. When LPN 1 responded to the room, NA 1 and NA 2 were with Resident 1, Resident 1 was, dangling on the safety sling that was wrapped around her back and sides of her chest, and her knees were buckled. LPN 1 informed the surveyor that she, placed a wheelchair behind the resident and the 3 of them placed her into the wheelchair. LPN 1 informed the surveyor that Resident 1 was assisted back to bed and that Resident 1 did not have any redness or bruising present at that time. LPN 1 was asked if the resident was assessed by the Registered Nurse in charge, and she stated, I only informed him that Resident 1 didn't do well with the lift. LPN 1 confirmed that no event report of the incident was initiated at that time. LPN 1 informed the surveyor that on the evening of June 12, 2016, NA 3 brought Resident 1, who was in her wheelchair, to the doorway of Resident 1's room to reveal bruises on her right breast and right inner elbow. LPN 1 said she stated to NA 3, I know how that happened and she reported the bruising to RN 1 and informed him about the incident that occurred on June 8, 2016. RN 1 performed the skin assessment on Resident 1 and documented the measurements as a right breast bruise area to be 19 centimeters (metric unit of measurement) by 7 centimeters in size and the right inner elbow bruise measured 5 centimeters by 2.5 centimeters. LPN 1 stated that she was notified by the facility administration staff on June 13, 2016, to explain what occurred on June 8, 2016 in Resident 1's room. Review of the facility investigation dated June 12, 2016, for the incident that involved Resident 1, revealed bruising was found on Resident 1's right breast and on her inner right elbow on June 12, 2016, at 7:21 p.m. by Nurse Aide 3, NA 3, and was reported to Licensed Practical Nurse 1, LPN 1. LPN 1 reported the bruising to Registered Nurse 1, RN 1, a Nursing Supervisor. RN 1 performed a skin assessment on Resident 1 and documented, medial antecubital bruising (inner part of the elbow) and right lateral breast bruising (right side of breast) present. The documentation revealed the right breast bruise area to be 19 centimeters (metric unit of measurement) by 7 centimeters in size and the right inner elbow bruise measured 5 centimeters by 2.5 centimeters. The report stated that Resident 1 was unable to recall how the bruising occurred. A phone call was made to Resident 1's physician on June 13, 2016, and he was informed that the resident experienced injury during stand lift transfer to right lateral chest wall and breast, extensive bruising and painful to touch. The physician ordered an X-ray to be performed on the resident's ribs. Review of the X-ray report dated June 13, 2016, revealed findings of subacute (recent onset) healing non-displaced (a break in the bone that remains aligned properly) fractures of the right rib cage with mild periosteal reaction (the formation of new bone in response to injury). Review of a nurses' note dated June 15, 2016, at 10:58 p.m. revealed that Resident 1 informed the staff that she doesn't wish to wear a bra because of her bruising. Review of the physician's orders for April through September 2016, failed to reveal any order for a lift, sling size or transfer status for Resident 1. Review of Resident 1's care plan failed to reveal any specific mechanical lift device or sling size. During an interview on September 9, 2016, at 2:30 p.m. the Nursing Home Administrator (NHA) stated that there are no physician's orders or care plan that address the mechanical lift type or sling size. The NHA did agreed that the policy should be followed. Review of the June 8, 2016, incident that occurred with Resident 1 and the review of the clinical record and staff interview, the facility staff failed to be knowledgeable of the facility policy and therefore failed to implement the facility policy and develop a comprehensive plan of care that provides care to residents with expected outcomes for the highest practicable physical wellbeing, that resulted in harm to Resident 1 evidenced by bruising, pain, and fractured ribs. 42 CFR 483.20(d)(3), 483.10(k)(2) Right to Participate Planning Care-Revise Cp. Previously cited 9/4/14. 28 Pa Code 211.11(a) Resident care plan. 28 Pa Code 211.11(d) Resident care plan. Previously cited 3/30/16.

Based on observations, facility policy reviews and staff interviews, it was determined that the facility failed to provide an environment that remained free of accident hazards related to the supervision of residents with access to liquids at temperatures exceeding 110 degrees Fahrenheit for one of three units (Rose Court), thereby placing the health and safety of the residents in Immediate Jeopardy. Based on observation and staff interview, it was determined that the facility failed to provide an environment that remained free of accident hazards related to medication cart accessibility for one of three units (Rose Court). Findings include: Observation of the Rose Court Café (Rose Unit Rehab Dining) area on August 3, 2015, at 11:55 a.m., revealed a coffee and hot water dispensing machine on the counter which was accessible to residents, both standing and seated in wheelchairs. Observed at this time were eight residents, Resident 6, 10, 17, 18, 19, 20, 21 and 22, who were sitting at the tables in the café area. Review of residents' most recent Brief Interview for Mental Status (BIMS - a set of standard interview questions utilized to determine an individual's attention, orientation and ability to register and recall new information. The answers are calculated and scores range from 0 to 15. A score of 0 to 7 indicate severe mental impairment, 8 to 12 indicate moderate impairment and score of 13 to 15 indicate a resident is cognitively intact. If a resident is unable to complete the interview due to impairment, a staff interview is performed to assess a resident's memory and judgment.) revealed the following: Resident 19 had a BIMS of 5 (severely impaired); Resident 22 had a BIMS of 3 (severely impaired); and Resident 18 was too cognitively impaired to participate in the interview. During the observation on August 3, 2015, at 11:55 a.m., of the aforementioned residents seated in the Rose Court Café, there were no staff supervising the residents. On August 3, 2015, at 12:20 p.m., observations in the café revealed residents with no supervising staff present. The hot water temperature of the water dispensing machine was 155.8 degrees Fahrenheit and the coffee temperature was 149.2 degrees Fahrenheit at 12:20 p.m. During this observation the aforementioned residents were seated in the Rose Court Café with no staff supervision. On August 3, 2015, at 12:30 p.m., information regarding the Nescafe Alegria V-Café 2/120 coffee dispenser and policies for the use of the Rose Court Café were requested from the Nursing Home Administrator (NHA). Review of the policy for the use of the Rose Court Café area revealed no policy for the supervision of residents using the café. On August 3, 2015, at 1:10 p.m., the NHA was notified that Immediate Jeopardy had been identified related to the lack of supervision of the residents in the Rose Court Café which had a coffee and hot water dispenser accessible to the residents. At this time, the NHA was asked to provide a corrective action plan. During this interview the NHA revealed that the coffee machine can produce hot liquids that are not to exceed 160 degrees Fahrenheit and that this is an acceptable temperature for the machine to dispense hot liquids. On August 3, 2015, at 1:21 p.m., the facility unplugged the coffee and hot water dispenser machine. The coffee and hot water machine was removed from the Rose Court Café and stored in the facility kitchen where it was not accessible to residents at 1:35 p.m. On August 3, 2015, at 3:00 p.m., the NHA submitted a corrective action plan. The plan revealed that the coffee and hot water dispenser machine was removed from the rehab dining room, the facility staff would be educated not to put the coffee and hot water dispenser machine back in the Rose Court Cafe and the remainder of the facility was checked to make sure that there were no other access issues. The corrective action plan was approved at 3:06 p.m. On August 4, 2015, at 9:20 a.m., the review of facility documentation, staff education, and observations revealed that the corrective action plan had been implemented. At 9:30 a.m., the NHA and the Director of Nursing were notified that the Immediate Jeopardy, regarding the lack of supervision of the residents in the Rose Court Café, which had a coffee and hot water dispensing machine that dispensed hot liquid at a temperature of 155.8 degrees and 149.2 degrees accessible to the residents, was lifted. During an observation of the Rose Court Unit on August 3, 2015, at 4:57 p.m., it was observed that an unattended medication cart was unlocked and located in the hallway outside of room 101. An observation of the medication cart revealed that all of the drawers were able to be opened. Observation from the medication cart revealed that no staff were visible from the location of the medication cart. Licensed Practical Nurse 2 (LPN 2) was observed returning to the medication cart at 5:02 p.m. during the process of medication administration. During an interview at 5:02 p.m., LPN 2 revealed that the medication cart should have been locked. The cart contained presription medication for the residents on the Rose Court Unit. During an interview on August 5, 2015, at approximately 2:30 p.m., the NHA revealed it is the facility's expectation that medication carts are locked if staff are not present. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices Previously cited 9/4/2014, 10/17/2013 28 PA Code 211.12 (c) Nursing Services Previously cited 9/4/2014 28 PA Code 211.12 (d)(1) Nursing Services Previously cited 1/14/15, 9/4/2014, 10/17/2013