Every finding on record at Oil City Nursing and Rehab

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to thoroughly investigate an incident reported to the State agency for one of 13 residents reviewed (Resident R1).Findings include: Review of Resident R1's clinical record revealed an admission date of 7/6/26, with diagnoses that include schizophrenia (impaired thinking process), chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), hypertension (high blood pressure), and obstructive and reflux uropathy (a condition that will not let the urine drain naturally). Review of information submitted by the facility dated 7/10/26, revealed that Resident R1 had fallen outside and obtained two skin tears to his/her left forearm and a hematoma to his/her left forehead. The report also indicated that Resident R1 had been outside with family and family had left and that Resident R1's family was educated to alert staff when they are leaving. Review of Resident R1's incident report note dated 7/10/26, indicated that staff were not aware that Resident R1 was outside. Review of the facility's investigation for Resident R1 revealed staff statements dated 7/9/26, that Resident R1's family had brought him/her back into the facility between 12:30 p.m. and 12:45 p.m. and laid him/her down in his/her bed. Staff statement indicated that Resident R1 was not observed leaving his/her room after being laid down by his/her family. The investigation indicated that on 7/9/26, at 1:45 p.m. Resident R1 was found outside on the ground due to a delivery man calling for help. The investigation did not indicate which family members had Resident R1 outside or brought him/her back into the facility and laid him/her down in bed. The investigation lacked statements from those who responded to Resident R1's incident being outside on the ground. During an interview on 8/19/26, at 2:16 p.m. the Director of Nursing (DON) revealed that on 7/9/26, Resident R1 was lying outside on the ground and a delivery man was standing with Resident R1. The DON confirmed that Resident R1 was outside by him/herself without supervision and/or monitoring. The DON also confirmed that the investigation lacked evidence that the incident was thoroughly investigated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 19 residents reviewed (Resident R96). Findings include: Resident R96's clinical record revealed an admission date of 2/18/26, with diagnoses that included syncope and collapse, end stage renal disease, and dependance on dialysis (life sustaining treatment that filters waste, excess fluid and salt from the blood when kidneys are no longer functioning properly). Clinical record review revealed a nurse's note dated 2/27/26, that Resident R96 was at dialysis and would not be able to receive dialysis due to a decline in health status and was sent to the hospital. As of 3/27/26, Resident R96's clinical record revealed an Minimum Data Set (MDS-periodic assessment of resident care needs) dated 2/27/26, that indicated discharged return anticipated. Resident R96's clinical record lacked evidence of the status of the resident after being sent to the emergency room from dialysis, as of 3/27/26. During an interview on 3/27/26, at 11:30 a.m. the Director of Nursing confirmed that Resident R96's clinical record did not reflect the resident's status after being sent to the hospital while at dialysis on 2/27/26. 28 Pa. Code 211.5(f)(iv) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 19 residents reviewed (Resident R60). Findings include: A facility policy entitled, Care Plans, Comprehensive Person-Centered dated 10/29/24, indicated that assessments of residents are on-going and care plans are revised as information about the resident and the resident's condition changes, and the interdisciplinary team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents). Resident R60's clinical record revealed an admitted [DATE], with diagnoses that included long-term kidney disease, sudden kidney failure, and high blood pressure. Review of Resident R60's clinical record revealed a physician's order dated 6/18/24, for removal of his/her dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) catheter (a soft, flexible tube used to access a patient's blood for hemodialysis). A departmental progress note dated 6/21/24, indicated that the dialysis catheter was removed due to Resident R60 no longer requiring dialysis treatment. A care plan entitled end stage renal disease initiated 6/05/24, with the most recent target date of 11/16/24, included interventions to transport Resident R60 to dialysis on Tuesdays and Saturdays at 10:30 a.m., coordinate dialysis care with the dialysis treatment facility, arrange for transportation to and from dialysis, and confer with physician and/or dialysis treatment facility regarding changes in medication administration times/dosages pre-dialysis as needed. Review of Resident R60's MDS's revealed the following: Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Significant Change in Status Assessment MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Significant Change in Status Assessment MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Interview on 3/12/25, at 12:57 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R60's care plan lacked evidence of being updated to reflect the current necessary care and services. 28 Pa. Code 211.5(f)(ii) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of seven residents reviewed for psychotropic medications (Resident R58). Findings include: Resident R58's clinical record revealed an admission date of 4/26/24, with diagnoses that included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), Psychosis (when people lose some contact with reality), anxiety, and high blood pressure. A physician's order dated 2/08/25, instructed staff to administer Lorazepam 0.5 mg by mouth every eight hours PRN for anxiety or agitation, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of Resident R58's MAR revealed he/she received the Lorazepam once on 2/25/25 and 3/04/25. During an interview on 3/13/25, at 8:46 a.m. the Social Worker confirmed that Residents R11 and R58's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms (Units A, C, and D medication room). Findings include: A facility policy entitled, Medication Storage in the Facility-Controlled Substance Storage dated 10/29/24, indicated that Schedule II-V (controlled substances that have an increased risk of resulting in addiction and/or substance use disorder) medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separated from all other medications. Observation on 2/26/25, at 1:26 p.m. of the Unit A, C, and D medication refrigerator revealed one locked compartment that contained two boxes of injectable Lorazepam (controlled substance used to treat anxiety disorders) was affixed to the rack of the refrigerator and that the rack was not permanently affixed inside the refrigerator. During an interview at that time, the Assistant Director of Nursing confirmed that the refrigerator rack was not permanently affixed to the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure fluid intake and urinary output were documented as per physician's orders in the Treatment Administration Record (TAR) and in the Tasks Record for two of three residents reviewed with foley catheters (a medical device with tubing that drains urine from the bladder) (Residents R49 and R83). Findings include: The facility policy entitled Emptying a Urinary Drainage Bag, dated 10/29/24, revealed to empty the urinary drainage bag at least every eight hours and document the amount of urine emptied from the drainage bag. The facility policy entitled Intake, Measuring and Recording, dated 10/29/24, revealed the amount of liquids consumed should be recorded in the resident's medical record. Resident R49's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of diseases in the lungs that block airflow making it difficult to breath), hypertension (high blood pressure), and chronic kidney disease. Review of Resident R49's physician's orders dated 1/7/25, revealed an order to document fluid intake and foley output every shift. Review of R49's TAR which is completed by the Licensed Nurses for January 2025, February 2025, and March 2025 revealed his/her fluid intake and urinary output were not documented every shift per physician's orders on 1/7/25, 1/8/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/17/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/28/25, 2/13/25, 2/14/25, 2/17/25, 2/18/25, 2/20/25, 2/21/25, 2/22/25, 2/24/25, 3/3/25, and 3/11/25. Review of R49's Tasks Record which is completed by Nursing Assistants from 2/11/25 through 3/11/25, revealed his/her fluid intake was not documented every shift per physician's orders on 2/14/25, 2/17/25, 2/22/25, 2/25/25, and 3/5/25, and urinary output was not documented every shift per physician's orders on 2/14/25, 2/28/25, 3/1/25, 3/4/35, and 3/5/25. Resident R83's clinical record revealed an admitted [DATE], with diagnoses that included rhabdomyolysis (muscle breakdown that damages kidneys due to protein in the blood), weakness, and malignant neoplasm of prostate (cancer of the prostate gland). Review of Resident R83's physician's orders dated 1/31/25, revealed an order to document fluid intake and output every shift. Review of R83's Treatment Administration Record (TAR) which is completed by the Licensed Nurses for February 2025 and March 2025 revealed his/her fluid intake and urinary output were not documented every shift per physician's orders on 2/1/25, 2/7/25, 2/13/25, 2/14/25, 2/15/25, 2/17/25, 2/18/25, 2/20/25, 2/21/25, 2/22/25, 2/24/25, 3/3/25, and 3/11/25. Review of R83's Tasks Record which is completed by Nursing Assistants from 2/11/25 through 3/11/25, revealed his/her fluid intake was not documented every shift per physician's orders on 2/14/25, 2/17/25, 2/22/25, 2/25/25, 3/5/25, and urinary output was not documented every shift per physician's orders on 2/14/25, 2/28/25, 3/1/25, 3/4/25, and 3/5/25. During an interview on 3/12/25, at 10:46 a.m. the Director of Nursing confirmed that the clinical records lacked evidence that the TAR and Tasks Record documentation were completed per physician's orders for fluid intake and urinary output for Residents R49 and R83 on the dates listed above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to implement appropriate safety measures in a manner that protected a resident from injury of unknown origin and resulted in actual harm when the resident received an ankle fracture that required medical treatment at a hospital for one of 18 residents reviewed (Resident R15). Findings include: Review of a facility policy entitled Investigating Injuries dated 2/20/24, revealed that an Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury The policy also indicated with the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours. Review of facility policy entitled Lifting Machine, Using a Mechanical dated 2/20/24, indicated that at least two staff are needed to safely move a resident with a mechanical lift. Review of the Job Description Nurse Aide (NA) revealed that the nurse aide will provide quality routine daily nursing care to residents according to the residents' care plan. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included fractured left hip, pressure ulcer left heel, and atrial fibrillation (abnormal heart rhythm). Review of Resident R15's quarterly Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated [DATE], revealed that Resident R15 was cognitively impaired and his/her transfer status was an extensive assist, two-person physical assist. Review of a Physical Therapy Treatment Encounter Note dated 3/14/24, revealed Resident R15 was a maximal assist of two for standing. During an interview on 4/4/24, at 10:35 a.m. with the Director of Physical Therapy Employee E1 confirmed Resident R15 was a maximal assist of two for all transfers. Review of Resident R15's physician's orders dated 3/15/24, revealed an order for extensive assist times two, stand and pivot for transfers and showers. The physician orders lacked any orders for the use of any mechanical lift. Review of a nurse's note dated 3/19/24, at 1:18 p.m. by Assistant Director of Nursing (ADON) revealed that Resident R15 had increased pain, bruising and swelling to the left lower extremity, physician notified, and orders received for x-ray of left foot and ankle. Nursing note written by Registered Nurse (RN) Employee E2 at 5:02 p.m. x-ray results revealed acute bimalleolar fracture deformity of the left ankle, orders received to send Resident R15 to the emergency room . Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E3 revealed that he/she had transferred Resident R15 on 3/17/24, using the sit-to-stand mechanical lift in the shower area with only an assist of one. Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E4 revealed that he/she was providing care at 8:45 a.m. on 3/18/24, and noticed a bruise on Resident R15's ankle. Review of the Employee Witness Statement Form written by the ADON on 3/22/24, revealed that NA Employee E5 was providing care for Resident R15's roommate with the curtain closed and stated that NA employee E6 transferred Resident R15 from chair to bed alone using the sit-to-stand mechanical lift. When NA Employee E5 finished caring for the roommate he/she helped NA Employee E6 with care for Resident R15 who was in bed at that time. Review of the Employee Witness Statement form written on 3/19/24, by NA Employee E6 revealed that he/she transferred Resident R15 into bed with assist of two at approximately 7:15 p.m. and that around 9:55 p.m. Resident R15 wanted out of bed due to foot pain, NA Employee E6 indicated that he/she would inform the nurse regarding the resident's complaint of pain. During an interview on 4/4/24, at 2:45 p.m. NA Employee E6 indicated that he/she transferred Resident R15 from chair to bed using an assist of two but could not recall who assisted and NA Employee E6 could also not recall whom he/she notified of Resident R15's complaint of foot pain. Review of Resident R15's clinical record revealed no documentation regarding the resident's complaint of foot pain or any bruising until 3/19/24, at 1:55 p.m. The only other statements in the investigation were written by Licensed Practical Nurse (LPN) Employee E7 who worked the day shift on 3/18/24 and the NA Employee E8 who had never gotten the resident out of bed since the resident's admission. Review of an incident report dated 3/19/24, at 1:21 p.m. revealed that Resident R15 complained of left lower leg pain and had bruising. The resident had no falls or incidents of rolling out of bed. Resident is cognitively impaired and unable to state how the injury happened. Review of an x-ray completed at the hospital on 3/19/24, revealed an acute bimalleolar fracture deformity of the left ankle. Review of information submitted by the facility dated 3/19/24, identified that Resident R15 is identified as a two-person assist with transfers. Investigation with staff and resident revealed no inconsistencies of how care was provided, and staff witness statements did not indicate where or how the injury occurred. Review of Resident R15's clinical record and documentation of incident investigation lacked evidence that a full investigation was completed. The information lacked statements from all staff working during the timeframe when the alleged incident may have occurred from 3/17/24 until 3/19/24, at 1:55 p.m. when Resident R15's left lower leg had bruising and swelling documented. During an interview on 4/5/2024, at 9:45 a.m. the Nursing Home Administrator confirmed that the investigation completed on Resident R15's incident with injury of unknown origin was incomplete and had inconsistent statements that should have been further investigated. The NHA also confirmed that the investigation did not reveal how Resident R15 sustained an ankle fracture and there was no physician's order for a sit-to-stand lift. The facility failed to provide safety measures that resulted in actual harm of an ankle fracture to Resident R15. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records and facility documentation, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury of unknown origin for one of 18 residents reviewed (Resident R15). Findings include: Review of a facility policy entitled Investigating Injuries dated 2/20/24, revealed that an Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury The policy also indicated with the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included fractured left hip, pressure ulcer left heel, and atrial fibrillation (abnormal heart rhythm). Review of Resident R15's quarterly Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated [DATE], revealed that Resident R15 was cognitively impaired and his/her transfer status was an extensive assist, two-person physical assist. Review of a Physical Therapy Treatment Encounter Note dated 3/14/24, revealed Resident R15 was a maximal assist of two for standing. During an interview on 4/4/24, at 10:35 a.m. the Director of Physical Therapy Employee E1 confirmed Resident R15 was a maximal assist of two for all transfers. Review of a nurse's note dated 3/19/24, at 1:18 p.m. by Assistant Director of Nursing (ADON) revealed that Resident R15 had increased pain, bruising and swelling to the left lower extremity, physician notified, and orders received for x-ray of left foot and ankle. Nursing note written by Registered Nurse (RN) Employee E2 at 5:02 p.m. for x-ray results revealed acute bimalleolar fracture deformity of the left ankle, orders received to send Resident R15 to the emergency room . Review of the Employee Witness Statement Form written on 3/19/24, by Nursing Assistant (NA) Employee E3 revealed that he/she had transferred Resident R15 on 3/17/24, using the sit-to-stand lift in the shower area with only an assist of one. Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E4 revealed that he/she was providing care at 8:45 a.m. on 3/18/24, and noticed a bruise on Resident R15's ankle. Review of the Employee Witness Statement Form written by the ADON on 3/22/24, revealed that NA Employee E5 was providing care for Resident R15's roommate with the curtain closed and stated that NA employee E6 transferred Resident R15 from chair to bed alone using the sit-to-stand lift. When NA Employee E5 finished caring for the roommate, he/she helped NA Employee E6 with care for Resident R15 who was in bed at this time. Review of the Employee Witness Statement form written on 3/19/24, by NA Employee E6 revealed that he/she transferred Resident R15 into bed with assist of two at approximately 7:15 p.m. and that around 9:55 p.m. Resident R15 wanted out of bed due to foot pain. NA Employee E6 indicated that he/she would inform the nurse regarding the resident's complaint of pain. During an interview on 4/4/24, at 2:45 p.m. NA Employee E6 indicated that he/she transferred Resident R15 from chair to bed using assist of two but could not recall who assisted and NA Employee E6 could also not recall whom he/she notified of Resident R15's complaint of foot pain. Review of Resident R15's clinical record revealed no documentation regarding the resident's complaint of foot pain or any bruising until 3/19/24, at 1:55 p.m. The only other statements in the investigation were written by Licensed Practical Nurse (LPN) Employee E7 who worked the day shift on 3/18/24 and the NA Employee E8 who had never gotten the resident out of bed since the resident's admission. Review of an incident report dated 3/19/24, at 1:21 p.m. revealed that Resident R15 complained of left lower leg pain and had bruising. The resident had no falls or incidents of rolling out of bed. Resident R15 was cognitively impaired and unable to state how the injury happened. Review of an x-ray completed at the hospital on 3/19/24, revealed an acute bimalleolar fracture deformity of the left ankle. Review of information submitted by the facility dated 3/19/24, identified that Resident R15 was identified as a two-person assist with transfers; investigation with staff and resident revealed no inconsistencies of how care was provided, and staff witness statements did not indicate where or how the injury occurred. Review of Resident R15's clinical record and documentation of incident investigation lacked evidence that a full investigation was completed. The information lacked statements from all staff working during the timeframe when the alleged incident may have occurred from 3/17/24 until 3/19/24, at 1:55 p.m. when Resident R15's left lower leg had bruising and swelling documented. During an interview on 4/5/2024, at 9:45 a.m. the Nursing Home Administrator confirmed that the investigation completed on Resident R15's incident with injury of unknown origin was incomplete and had inconsistent statements that should have been further investigated. The NHA also confirmed that the investigation should have been more thorough with additional staff witness statements. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide oxygen for one of three residents reviewed for respiratory services according to a physician's orders (Resident R30). Findings include: Review of a facility policy entitled Oxygen Administration dated 1/24/23, stated Verify that there is a physician's order and Review physician's order for oxygen administration. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia, high blood pressure, and chronic obstructive pulmonary disease (COPD - a lung disease that causes difficulty breathing) Observation of Resident R30's oxygen flow meter (a medical device used for oxygen flow measurement) on 4/12/23, at 11:23 a.m. revealed the oxygen flow measurement was at four liters per minute through a nasal cannula (a tube that delivers oxygen to your nose through soft prongs). Observation of Resident R30's oxygen flow meter on 4/14/23, at 9:23 a.m. revealed the oxygen flow measurement was at four liters per minute through a nasal cannula. During an interview on 4/14/23, at 9:23 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the oxygen administration level was set at four liters per minute through a nasal cannula. During review of the clinical record with LPN Employee E1 on 4/14/23, at 9:26 a.m. it was confirmed that the clinical record lacked a physician's order for oxygen therapy for Resident R30. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(g)(h) Clinical records

Based on observations, review of facility policy, and staff and resident interviews, it was determined that the facility failed to provide meals that were palatable and at an appetizing temperature for three of 18 residents reviewed (Residents R16, R37 and R51). Findings include: The Food And Nutrition Services policy, dated 1/19/21, revealed food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and is served at a safe and appetizing temperature. Review of Resident Council Minutes from April 2021 revealed residents attending the council meeting complained of mushy vegetables. During an interview on 7/12/21, at 1:14 p.m., Resident R16 stated that the food has gotten worse. He/she stated that the residents receive a lot of the same foods, the vegetables are over cooked and the food and coffee is cold when the tray is delivered to the room. During an interview on 7/13/21, at 9:50 a.m., Resident R51 had concerns that the potatoes in potato salad are not cooked enough and the vegetables are mushy. Observation of the meal delivery to resident rooms on D Hall on 7/13/21, between 12:05 p.m. and 12:15 p.m. was conducted with the Registered Dietitian (RD). At 12:17 p.m., a test tray was evaluated for temperature and flavor. The following results were obtained: Hamloaf 90 degrees Farenheit (°F ) and was luke warm Beans 100°F texture was mushy Coffee 90°F and was not hot All results were confirmed with the RD and that the temperature of the food above was not hot enough and palatability of vegetables was somewhat mushy on 7/13/21, at 12:17 p.m. During a group meeting on 7/13/21, at 2:00 p.m., Resident R37 revealed that their food and coffee is usually served cold. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and staff and resident interviews, it was determined that the facility failed to include the resident in the care plan interdisciplinary meetings for three of 18 residents (Residents R2, R51 and R54). Findings include: The Resident Care Plan Conference Process policy, dated 1/19/21, revealed that (3) Social Service personnel or designee will document in the resident's medical record that the invitation to attend has been provided to the resident and/or resident representative and (4) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident and (5) the resident will be informed of his or her right to participate in his or her treatment and (7) the Care Plan/IDT note will be documented in the resident's record. Resident R54's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), dated 6/16/21, revealed that Resident R54 was alert and oriented. The clinical record lacked any evidence that Resident R54 was invited to care plan conference meetings. During an interview on 7/13/21, at 9:57 a.m. Resident R54 disclosed that he/she had not attended and/or was not invited to a care plan meeting. Resident R2's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked any evidence that Resident R2 was invited to care plan conference meetings. During an interview on 7/14/21, at 9:45 a.m. the Social Worker identified that there was no evidence of Resident R2 and R54 being invited to the care plan meetings. Resident R51's clinical record revealed an admitted 11//30/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE], revealed Resident R51's cognition was moderately impaired. Care plan meetings for Resident R51 were conducted on 2/10/21, and 5/18/21, as identified in the Care Plan Meeting facility document and there was no evidence that the resident attended the meetings on either day. During an interview on 7/13/21, at 9:50 a.m. Resident R51 had no recollection of an invite to a care plan meeting about their care. During an interview on 7/13/21, at 9:56 a.m., the Director of the Memory Care Unit confirmed there was no evidence that Resident R51 had been invited to the care plan meeting. 28 Pa. Code 211.11(e) Resident care plan

Based on review of clinical records and facility policies and staff and resident family interviews, it was determined that the facility failed to show evidence of having Resident Care Plan Conference meetings and also failed to have the required Interdisciplinary Team (IDT), members in attendance for five of 18 residents (Resident R2, R11, R29, R51 and R54). Findings include: The Resident Care Plan Conference Process policy, dated 1/19/21, revealed that (3) Social Service personnel or designee will document in the residents medical record that the invitation to attend has been provided to the resident and/or resident representative and(4) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident and (5) the resident will be informed of his or her right to participate in his or her treatment and (7) the Care Plan/IDT note will be documented in the resident's record. Resident R2's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence to show that Resident R2 had a Care Plan Conference meeting since 1/30/20, a period of over 19 months. Resident R54's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked any evidence that Resident R54 was invited or participated in care plan conference meetings. There was no evidence to show that Resident R54 had a Care Plan Conference meeting since admission on 6/09/20, a period of over 13 months. During an interview on 7/14/21, at 9:45 a.m. the Social Worker confirmed that there was no evidence of Care Plan Conference Meetings for both Resident's R2 and R54. Resident R29's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked evidence of Resident R29 and/or the family participating in a care plan meeting in association with Minimum Data Set (MDS - federally mandated assessments of resident care needs and directing the plan of care) assessments conducted in November 2020, February 2021, April 2021 and May 2021. During an interview on 7/21/21 at 3:10 p.m., Resident R29's Family Member indicated that prior to the COVID-19 pandemic he/she used to attend care plan meetings, but that since that time the facility kind of calls with updates . I'm not sure you'd call that a care plan meeting or not. During an interview on 7/14/21, at 12:59 p.m., the Director of Memory Care who oversees care plan meetings in that unit confirmed that there was no evidence to support that Resident R29 and his/her family participated in a recent care plan meeting, stating we've just been updating the families. Resident R11 was admitted the facility on 2/08/18, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan meetings conducted on 3/24/21 had no IDT members present during the meeting and on 5/21/21 there was only a Licensed Practical Nurse in attendance at the meeting. Resident R51 was admitted to the facility on 11//30/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE], revealed Resident R51's cognition was moderately impaired. Care plan meetings for Resident R51 were conducted on 2/10/21 and 5/18/21 per the Care Plan Meeting facility document and there were no evidence that any IDT members had attended the care plan meetings. During an interview on 7/13/21, at 9:56 a.m. the Director of the Memory Care Unit confirmed there was either only one or no interdisciplinary members present at Resident R11 or R51's care plan meetings. The Director of Memory Care stated that IDT members attend care plan meetings for new residents however they do not for long standing Memory Care residents. 28 Pa. Code 211.11(e) Resident care plan

Based on observations, review of the daily menus and facility policy, and staff and resident interviews, it was determined that the facility failed to offer alternate meals that provide residents with alternate preferences meeting their nutritional requirements for eight of 18 residents interviewed (Residents R16, R51, R9, R25, R34, R37, R41, and R28). Findings include: The Menus policy, dated 1/19/21, revealed (1) menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutritional Board, (9) if a food group is missing from a residents daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. During an interview on 7/12/21, at 1:14 p.m. Resident R16 indicated the alternate menu of the always available choices are posted, however that menu doesn't change: i.e . hamburgers, hot dogs, salads. During an interview on 7/13/21, at 9:50 a.m. Resident R51 was not aware that there was an alternate meal to choose daily besides the always available menu. During observation of the tray line service on 7/13/21, at 11:21 a.m. the day cook had identified that the main meal was hamloaf and the alternate was stuffed cabbage. The Dietary Manager stated that the main menu food is served and if the resident has indicated on their meal ticket a dislike of the main menu food, the resident would receive the alternate. If the resident disliked both meals, then the resident could choose from the always available menu. Observation of the menu boards on 7/13/21, at 11:35 a.m. revealed that the menus were posted outside the dining room and at the nursing station and only provided information about the main course meal. The board lacked information regarding the alternate that was available for the lunch meal on 7/13/21. During an interview on 7/13/21, at 11:55 a.m. with the Registered Dietitian (RD), Resident R16 and R9, it was identified that the residents were unaware that stuffed cabbage was the alternate on the menu on 7/13/21. Both residents stated they would pick off the always available menu if they did not like the main meal and were not aware that there was an alternate meal to choose each day. Both Residents R16 and R9, thought they could only pick from the always available menu (hot dogs, hamburger, grilled cheese etc .) Resident R16 also stated that they did not have a menu in their room, and only knew what was served by looking on the board on the wall. During an interview on 7/13/21, at 11:55 a.m. Resident R25 stated to the RD that he/she did not know there was stuffed cabbage as an alternate meal and he/she would like it for their meal. During an interview on 7/13/21, at 11;55 a.m. the RD confirmed that the alternate menu was not displayed on the board for residents to choose those items and that residents appeared to be unaware that there was an alternate meal prepared each day if the main meal was not desired. During a group meeting conducted on 7/13/21, between 2:00 p.m. to 2:40 p.m. Residents R34, R37, R28 and R41 indicated they were unaware of a daily alternate meal available to choose from if the main meal was disliked. The facility failed to ensure that residents were aware that there was an option of an alternate meal with nutritional equality to the main meal as their choice. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that baseline care plans were reviewed with residents and/or their representative and that a copy of the baseline care plan was provided to the resident and/or the resident's representative for five of 18 residents reviewed (Residents R59, R9, R28, R32, and R54). Findings include: Resident R32's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. Resident R54's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. Resident R59's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. Resident R9's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. Resident R28's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record included a care plan, developed upon admission, but lacked evidence/documentation that the baseline care plan was reviewed with the resident and/or the resident representative or that a copy was provided. During an interview on 7/14/21, at 12:49 p.m., the facility's Registered Nurse Assessment Coordinator confirmed that baseline care plans were not reviewed with new admissions or that a copy was provided to newly admitted residents and/or the resident representative. 28 Pa. Code 211.11(c)(e) Resident care plan

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the state mental health authority after a significant change in the mental or physical condition of one of one residents reviewed with a positive screen for serious mental illness as assessed by a Preadmission Screening and Resident Review (PASRR - a state assessment to determine appropriate placement in long term care and the provision of services for identified mental illness [MI], intellectual disability [ID]/developmental disability [DD], or other related conditions [ORC]) and a Level II assessment (an additional assessment to determine if certain care and services are required to be provided by the facility and/or specialized services provided by the state). Findings include: Resident R55's clinical record revealed an original admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record further reflected four admissions (5/20/21, 3/21/21, 1/10/21 and 11/01/20) to the hospital in the last eight months and a general decline in condition related to cardiac, renal and gastrointestinal disease. A Significant Change Minimum Data Set assessment (MDS - a federally mandated periodic assessment of resident care needs), dated 6/16/21, reflected a decline in Resident R55's condition marked by an unstageable pressure ulcer (unable to determine the depth/stage of the wound), weight loss and the initiation of hospice services (end-of-life care). Resident R55's clinical record included a PASRR form, dated 9/24/18, that indicated that Resident R55 had a positive screen for Serious MI, ID/DD, and/or ORC and required a PASRR Level II evaluation. The record included a letter from the Pennsylvania Department of Human Services Office of Mental Health and Substance Abuse Services, dated 2/26/19, indicating Resident R55 was assessed by the department as eligible for the level of service provided by the nursing facility and was also eligible for additional mental health services for mental illness as arranged by the facility with available assistance of the county mental health office. The clinical record lacked evidence that the state mental health authority was notified of Resident R55's significant change in condition, as documented in the 6/16/21, Significant Change MDS, related to the initiation of hospice services. During an interview on 7/14/21, at 12:52 p.m., the facility's Social Worker confirmed that the state mental health authority was not notified of Resident R55's significant change in condition as required. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident, or the resident's representative, following the end of Medicare covered services for two of two residents reviewed who remained in the facility for long-term care (Residents R2 and R38). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on 2/10/21, revealed that Medicare coverage for Resident R2, started on 1/7/21, and that the last covered day was 2/12/21. The form indicated that the facility initiated discharge from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide an SNF Advanced Beneficiary Notice of Non-coverage (ABN - provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) to the resident, or the resident's representative, as required in advance of the time that Medicare Part A was discontinued. A SNF Beneficiary Protection Notification Review form, completed by the facility on 5/24/21, revealed that Medicare coverage for Resident R38, started on 4/09/21, and that the last covered day was 6/04/21. The form indicated that the facility initiated discharge from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide an SNFABN to the resident, or the resident's representative, as required in advance of the time that Medicare Part A was discontinued. During an interview on 7/14/21, at 9:49 a.m. the Registered Nurse Assessment Coordinator confirmed that the facility did not provide SNFABN forms to Residents R2 and R38, or their representatives, when the facility discharged the residents from Medicare covered services. 28 Pa. Code 201.18(b)(2)(e)(1) Management

Based on observations, review of facility policies and staff interviews, it was determined that the facility failed to maintain infection control practices in the kitchen during food service in the main kitchen. Findings include: The Hand Washing policy, dated 11/19/19, revealed each employee will wash his or her hands to eliminate visible dirt and reduce the bacterial load .(j) after handling or removing trash, (k) anytime hands are soiled . Observations on 1/27/20, from 12:00 p.m. to 12:30 p.m. revealed that the Dietary Manager and the Cook both touched the lid of the garbage can and proceeded to put on gloves without first washing their hands. At the time of the observations, the Dietary Manager confirmed that hands should be washed before putting on gloves. 28 PA Code 211.6(f) Dietary services

Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to update skin/pressure ulcer, activities of daily living, and fall care plans for four of 23 residents reviewed (Residents R12, R32, R35 and R53). Findings include: Resident R12's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The Wound Evaluation Flow Sheet form dated 1/02/20, revealed that Resident R12 had developed an open area on the right outer ankle. There was no documented evidence that the skin care plan had been updated to include the identified new open area for Resident R12. Resident R35's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The Wound Evaluation Flow Sheet form dated 12/12/19, revealed that Resident R35 had developed an open area on the left heel. There was no documented evidence that the skin care plan had been updated to include the identified new open area for Resident R35. During an interview on 1/29/20, at 2:00 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that skin care plans for Residents R12 and R35 had not been updated to reflect the new open areas. Resident R32's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R32's clinical record revealed a physician's orders [REDACTED]. A physician's orders [REDACTED]. [REDACTED]. Resident R32's care plans did not identify the use of the interventions of the abductor wedge, left knee splint, left lateral body support, foot buddy, high-back wheel chair, and Sara lift. Observation on 1/27/20, at 3:05 p.m. of Resident R32 sitting up in his/her wheel chair with the left lateral body support, left knee splint, and knee wedge in place. During an interview on 1/29/20, at 12:00 p.m. the RNAC confirmed that Resident R32's care plans were not updated to include the above interventions. Resident R53's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A physician order, originally dated 1/21/20, revealed that Resident R53 was ordered contact isolation (precautions to assist in the containment of an infection) for an infection. Resident R53's care plans lacked evidence to indicate that the physician ordered isolation precautions were on the care plans. During an interview on 1/30/20, at 1:37 p.m. the Director of Nursing confirmed that Resident R53's care plan was not updated to include the contact isolation precautions ordered by the physician. 28 PA Code 211.5(f) Clinical records Previously Cited 12/07/18 28 PA Code 211.12(d)(1)(3)(5) Nursing services Previously Cited 12/07/18

Based on review of facility policies and staff and resident interviews, it was determined that the facility failed to include the resident in the care plan interdisciplinary meetings for one of 23 residents (Resident R21). Findings include: The Care Plans, Comprehensive Person-centered policy, dated 11/19/19, revealed that (1) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident and (5) the resident will be informed of his or her right to participate in his or her treatment and (6) an explanation will be included in the residents medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable. The Annual Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), dated 11/12/19, revealed that Resident R21 was alert and oriented. During an interview on 1/28/20, at 9:57 a.m. Resident R21 disclosed that he/she did not think they were invited to a care plan meeting. There was no evidence to show that Resident R21 was invited to the care plan meetings. During an interview on 1/30/20, at 10:45 a.m. the Social Worker (SW) identified that Resident R21's family does not attend the meetings, therefore Resident R21 was not asked to attend. The SW additionally confirmed that he/she was the only member of the IDT who attended Resident R21's meeting. 28 PA Code 211.11(e) Resident care plan

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a comprehensive care plan for [MEDICAL TREATMENT] services was developed for two of 23 residents reviewed (Residents R53 and R60). Findings include: An admission Minimum Data Set (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment for Resident R53, dated April 29, 2019, revealed [DIAGNOSES REDACTED]. There was no comprehensive care plan regarding care and services for [MEDICAL TREATMENT] services for Resident R53. Resident R60's admission MDS dated [DATE], revealed [DIAGNOSES REDACTED]. There was no comprehensive care plan regarding care and services for [MEDICAL TREATMENT] services for Resident R60. During an interview on 1/29/20, at 2:00 p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R53 and R60 did not have comprehensive care plans developed regarding their [MEDICAL TREATMENT] services. 28 PA Code 211.11(d) Resident care plan