Every finding on record at Paramount Nursing and Rehab at Fayetteville, LLC

Based on policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to provide a two-handled cup for one of 20 residents reviewed (Resident 65).Findings Include: Review of facility provided policy, titled Adaptive Devices, dated 2020, revealed, Adaptive eating devices will be available to all residents who need them to promote independence in dining. Adaptive devices will be available for residents at mealtime and snack time according to the individualized plan of care. Review of Resident 65's clinical record revealed diagnoses that included diabetes (a condition where the body is unable to regulate blood glucose levels) and muscle weakness (weakness in the muscles not explained by any medical diagnosis). Review of Resident 65's current physician's orders revealed an order for a two-handled sippy cup with all meals, with a start date of June 18, 2026. Observation of Resident 65 on July 28, 2026, at 9:59 AM, revealed Resident 65 sitting in bed eating breakfast and she did not have her two-handled sippy cup. Observation of Resident 65 on July 28, 2026, at 1:42 PM, revealed Resident 65 sitting in bed eating breakfast and she did not have her two-handled sippy cup. Observation of Resident 65 on July 30, 2026, at 8:45 AM, revealed Resident 65 sitting in bed eating breakfast and she did not have her two-handled sippy cup. Review of Resident 65's care plan revealed a focus area of, Nutrition, with a revision date of April 23, 2024, and an intervention of, two-handled sippy cup with all meals, dated June 18, 2026. Interview with the Nursing Home Administrator revealed that he would have expected that Resident 65 would have had his ordered adaptive equipment, as ordered, at all meals. 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, select facility document review, policy review, review of diet guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in accordance with professional standards of practice to meet the needs of each resident for one of nine residents reviewed (Resident 1). This failure resulted in an Immediate Jeopardy situation for Resident 1 as evidenced by a delay in provision of emergency services which resulted in death.Findings include:Review of facility policy, titled Emergency Procedure-Choking, with a last review date of January 23, 2025, revealed the following, in part, Trained staff will assist the resident which is choking by attempting to expel the foreign body from the airway. Conscious Resident-Standing or Sitting:1. Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. 4. Call for help, but stay with the resident. 6. If the resident cannot cough, only then should abdominal thrusts be performed as follows: a. Stand behind resident. b. Wrap your arms around the resident's waist. c. Make a fist with one hand. d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. e. Grasp your clenched fist with your other hand. f. Press your fist into the resident's upper abdomen with a quick upward thrust. g. Do not squeeze the ribcage. Contain the force of the thrust to your hands. h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious Resident Lying Down (or When Unable to Reach Around Resident): 1. Ease the resident as gently as possible to the floor. 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrusts as follows: a. Facing the resident, kneel down and straddle resident's upper thighs with your body. b. Place the heel of one hand on the resident' s upper mid-abdomen, below the ribcage and above the navel with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. 5. Perform finger sweep maneuver to check for a foreign body as follows: a. Keep the resident's face up. b. Perform the tongue-jaw lift to open the resident's mouth. (Note: Moving the lower jaw moves the tongue off the throat and opens the airway.) c. Perform the finger sweep using your index finger as a hook. (1) Insert your index finger into the resident's mouth alongside of the cheek and across the base of the tongue. (2)Try to remove any foreign objects. (3) Avoid pushing foreign objects deeper into the throat. (4) Turn the resident's head to one side if needed to sweep an object from the mouth. 6. Alternate steps four 4) and five (5) until the object is expelled. Arrange for the resident to be evaluated by a physician immediately after the foreign body airway obstruction has been removed. 7. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility. 8. Proceed with CPR immediately if the resident has no pulse or respirations.Review of Resident 1's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included a compression fracture (collapse of a vertebra possibly due to trauma or a weakening of the vertebra) of the second lumbar (lower part of the back) vertebra, altered mental status, and muscle weakness.Review of Resident 1's physician orders revealed the following orders: Regular diet Mechanical Soft texture, with thin consistency, Out of bed to gerichair with left arm support (Recline chair at rest and incline during meals), Advanced Directive DNR/Do Not Attempt Resuscitation; Speech Therapy (ST) Eval &Treat 3-5 days/week x 30 days for Swallow Eval, Dysphagia (difficulty swallowing) treatment; and Occupational Therapy (OT) 5-6 days a week x 30 days for Activities of Daily Living. All orders were dated September 10, 2025.Review of Speech Therapy Evaluation and Plan of Treatment dated September 10, 2025, completed by Employee 3 (Speech Language Pathologist) indicated that Resident 1 was referred to ST due to exacerbation of cognitive impairment, decreased safety awareness, decreased oral pharyngeal function, risk for weight loss, risk for aspiration and decreased functional activity. ST to assess and evaluate the least restrictive oral intake, develop & instruct in compensatory strategies and minimize aspiration risk and promote safety awareness.Review of Resident 1's Speech Therapy progress report note dated September 20, 2025, completed by Employee 3, indicated, Interventions provided: Swallow Tx [treatment]: facilitation of finger foods, facilitation of small bites/sips (1/2 to 1/3 tsp{teaspoon}), facilitation of rate control during oral intake of food/liquid presentation and modification of bolus sizes and order/method of food/liquid presentation. Pt and Caregiver Training: Instructed patient and primary caregivers in safe swallow techniques in order to facilitate improved functional abilities with 100% carryover demonstrated by primary caregivers.Review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment dated September 10, 2025, completed by Employee 11 (Occupational Therapist), indicated, Res[ident] noted with decreased safety awareness.Review of Resident 1's Occupational Therapy Progress Report note dated September 20, 2025, completed by Employee 11, indicated Resident 1 was provided education and encouragement to initiate self-feeding and increase intake. In addition, in supervision section, it was noted Completed on-site consultation between therapist and assistant regarding patient's current status and modified POT [plan of treatment]/goals. It was electronically signed by Employee 1 (Certified Occupational Therapy Assistant) and Employee 11.Review of Resident 1's progress notes revealed a note dated October 1, 2025, at 11:30 AM, completed by Employee 13 (Registered Nurse), that stated, At approximately 1130, resident observed choking during meal consumption. Staff encouraged resident to cough and brought resident to his room. Staff immediately initiated Heimlich maneuver and oral suctioning. Staff encouraged resident to cough, but resident was unable to cough productively due to medical conditions. Resident continued to exhibit airway obstruction, with blue facial color and unable to speak effectively. O2 via non rebreather mask placed on resident during Heimlich maneuver attempts. Emergency protocols initiated and 911 called. At 1157, resident observed to lose consciousness with no findings of spontaneous movement. Auscultation of chest revealed no audible heart sounds over a duration of one minute with no palpable carotid or radial pulse detected B/L [bilaterally-both sides]. Skin noted to be pale and warm to touch. Pupils fixed and dilated. MD [Medical Doctor] updated with new order for RN to pronounce death.Further review of Resident 1's progress notes revealed a late entry note dated October 1, 2025, at 12:57 PM, completed by Employee 6 (RN-Assistant Director of Nursing), that stated This nurse was informed of a possible choking incident around 11:40 AM when walking towards DON [Director of Nursing]/ADON [Assistant Director of Nursing] office. This nurse stopped at nurse's station, checked resident's POLST and noted resident was DNR, at this time RN Supervisor (Employee 13) was at desk on the phone w/[with] 911 operator reporting incident. This nurse then entered resident's room to find LPN [Licensed Practical Nurse] (Employee 2) attempting suction at bedside. 2 CNA's [Certified Nurse Aides] (Employees 4 and 5) at bedside, as well as 2 therapy staff [Employee 1 (Certified Occupational Therapy Assistant) and Employee 3]. This nurse made staff aware that he is a DNR with limited interventions and that they could continue Heimlich efforts and suctioning, O2 applied via nonrebreather mask to help with any oxygenation possible. Resident complexion at that time getting duskier, his eyes did follow staff in the room, small bursts of air exchange with notable wheezing while attempting Heimlich. Staff unable to visualize the blockage in resident's mouth, and suctioning only producing small amounts of mucous with tiny crumbs of debris, and air exchange had ceased completely. Unable to obtain O2 saturation, and residents color continued to deteriorate. Resident lost consciousness and face appeared pale while both hands appeared cyanotic. At this time staff directed to stand down, this nurse attempted to feel radial pulse which was not there, then attempted to auscultate apical pulse for >60 seconds with no pulse noted, pupils were non-responsive. RN supervisor (Employee 13) notified MD, MD giving order to pronounce resident's death at 11:57 AM.Review of witness statement written by Employee 1 (Certified Occupational Therapy Assistant) read, in part, At approximately 11:40 AM, I handed resident half of a soft beef enchilada approximately 2.5 inches in size. Resident quickly pushed half of the enchilada in his mouth. I provided visual and verbal cues to instruct resident to slow down numerous times. Resident continued to push the remaining enchilada he was holding into his mouth. I noticed resident having a blank stare and starting to exhibit labored breathing while still able to speak. I instructed resident to keep coughing. Resident stated, 'I can't'. I then immediately alerted Employee 2 and 3 for further assistance. Review of witness statement written by Employee 2 (Licensed Practical Nurse) read, in part, I was called to the dining room for resident choking. I noted he was awake and breathing with long wheezing respirations. No cyanosis noted at that time. I raised back of wheelchair to a full ninety degree angle with resident continuing to have air exchange. Coughed at one time and a moderate amount of mucous was expectorated. Staff present encouraged him to cough to which he replied in a whisper 'I can't'.' We took resident to his room, assisted him to his bed and placed lying on left side. Respirations at this time were deeper with good exchange. I attempted to suction orally obtaining a small amount of food like material and mucous. Unable to visualize any obstruction upon inspection of mouth. Continued to attempt oral suctioning when resident became unresponsive and cyanotic. Staff attempted abdominal thrusts several times without results. Review of witness statement written by Employee 3 read, in part, I entered the dining room and followed [Employee 2 (Licensed Practical Nurse)] to resident's room. I was saying to resident cough and clear throat. I put a napkin in front of him to see if he could be visually cued to spit it out or cough. I observed staff place resident in bed. [Employee 2] suctioned resident and I continued to tell him to cough. Review of witness statement written by Employee 4 (Nurse Aide) read, in part, I saw staff coming with resident down hall and they stated he was choking. I ran and grabbed the lift. There were two nurses [Employee 2 and other unidentified), a Speech Therapist [Employee 3 (Speech Language Pathologist)], and a therapy assistant [Employee 1] in the room. [Employee 5 (Nurse Aide)] and I got him in bed with the lift. I kept telling him to cough hard and he mouthed 'I can't'. [Employee 2 (Licensed Practical Nurse)] tried to suction him but nothing came out. I put my finger [in his mouth] and did the sweep to see if I could remove any food, but I couldn't feel anything. [Employee 6 (Registered Nurse-Assistant Director of Nursing)] then came in the room and told us he was a DNR. I then immediately started the Heimlich maneuver. It was around 11:50 AM. I continued until I got tired and then [Employee 5 took over. We continued off and on performing the Heimlich maneuver until [Employee 6] told us to stop to check for a pulse. [Employee 6] 6 checked for a pulse and it wasn't there. Determined resident expired around 12 noon. Review of witness statement written by Employee 5 read, in part, I assisted [Employee 4] with the lift. As we lowered him into bed, I kept telling him to cough repeatedly over and over but the resident mouthed 'I can't' without speaking any words. [Employee 2] tried suctioning without any success, [Employee 4 ] tried the finger sweep inside his mouth to try and remove any food, that is when [Employee 6] walked into the room and announced that resident was DNR limited status, at that time the Heimlich maneuver was started at approximately 11:50 AM by [Employee 4] and after she became tired I had taken over and had tried multiple times back and forth until [Employee 6] asked us to stop and check for a pulse and at that time no pulse was present. Resident was determined to had expired at 12:00 PM. Review of witness statement written by Employee 6 read, in part, [Employees 4 and 5 (Nurse Aides)] attempted Heimlich with [Employee 2 ] and my direction. Resident unable to clear bolus and unable to cough. He had no air movement, his color was mottled, and he had no pupil reaction. Pulse checked at this time, he had no pulse, attempted via stethoscope to auscultate a heartbeat, no heartbeat for greater than 60 seconds. Time of death declared 11:57 AM. During a staff interview with Employee 6 (RN-Assistant Director of Nursing) on October 3, 2025, at 1:03 PM, it was confirmed that Resident 1's choking incident started around 11:40 AM and that staff did not initiate the actual Heimlich Maneuver until approximately 11:50 AM, a delay of approximately 10 minutes.During a staff interview with Employee 2 on October 3, 2025, at 1:20 PM, Employee 2 said when she entered the dining room, Resident 1 was seated in his high back wheelchair at approximately a 75-80-degree angle. Employee 2 said she immediately raised Resident 1's chair to a full 90 degree angle. When Employee 2 was asked why the Resident was taken back to his room and transferred to bed before any emergency measures were initiated for the choking episode, she stated, He still had some air exchange and we wanted to get him out of the dining room away from the other residents. Employee 2 stated that Resident 1 went to the dining room for all meals and was on the assisted side of the dining room. Employee 2 confirmed that Resident 1 had poor safety awareness because of his cognitive impairment. Employee 2 also said that the typical process for someone on a mechanical soft diet was to have their food cut up into bite size pieces and that she could not speak as to why Employee 1 did not do this on the day Resident 1's choking incident occurred.Resident 1's room was located at the end of the hallway. During a staff interview and observation with Employee 9 (Maintenance Director) on October 3, 2025, at 3:07 PM, it was revealed that the distance from the dining room to Resident 1's room was approximately 138 feet. On October 3, 2025, at 3:12 PM, the Nursing Home Administrator (NHA) was informed that an Immediate Jeopardy situation had been identified and the IJ template was provided. An immediate action plan was requested. The NHA provided the facility's Immediate Action Plan on October 3, 2025, at 7:28 PM. The plan of action included: Choking policy was reviewed and updated to American Heart Association Standards. All nursing staff currently working in the building will be educated by the Assistant Director of Nursing on the revised choking policy. All other nursing staff will be educated by the Registered Nurse Supervisor prior to the start of their shift. This will include all full-time, part-time, and prn [as needed] nursing staff. The Assistant Director of Nursing will educate all nursing staff currently working on the signs to look for when someone is choking. This will include all full-time, part-time, and prn [as needed] nursing staff. The Rehab Manager audited all residents on current caseload immediately to ensure current Speech Therapy diet recommendations were being followed. The Rehab Manager will audit all residents who have had current Speech Therapy diet recommendations to ensure their current diet order reflects Speech Therapy recommendations. On October 4, 2025, meal service observations between 7:45 and 8:52 AM, revealed no concerns. Interviews, review of revised policy, review of education, and review of audits conducted on October 4, 2025, between 8:35 AM and 11:25 AM, revealed the facility had completed all immediate actions as stated in their plan. Interviews were conducted with 2 Registered Nurses, 2 Licensed Practical Nurses, and 4 Nurse Aides who were all able to state signs of choking and the immediate actions to take should a choking incident occur. They were all also able to indicate how Speech Language Pathologist diet recommendations would be communicated to them. Interviews were also conducted with a Speech Language Pathologist who was able to state the process to be followed to ensure that recommendations are communicated to the dietary department, and with a Certified Occupational Therapy Assistant who verbalized that a Speech Therapist's diet recommendations would be located on a resident's meal tray ticket. Interviews with two Dietary Aides revealed that they were both able to state the measures they are to take in preparing a resident's meal tray for delivery. An interview with the Dietary Manager revealed the process he had developed and implemented with the dietary staff to ensure a resident receives the appropriate diet and that Speech Language Pathologist recommendations are followed. On October 4, 2025, at 11:35 AM, the Immediate Jeopardy was lifted. During a final staff interview with the NHA on October 6, 2025, at 1:52 PM, she confirmed that she would have expected staff to have begun emergency measures for Resident 1's choking event immediately instead of taking the time to take him back to his room, transferring him back to bed, and waiting for further direction to start the Heimlich Maneuver. The facility failed to provide timely emergency services, including the Heimlich maneuver, to Resident 1 when he was choking. This failure resulted in an immediate jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, select facility document review, review of diet guidelines, review of select resident meal tray tickets, and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents based on individual needs for one resident (Resident 1), which resulted in Resident 1 choking. This failure placed nine residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation (Resident 6, 7, 8, 9, 10, 11, 12, 13 and 14).Findings include:Review of facility document, titled Mechanically Altered Diets, last reviewed January 23, 2025, read, in part, Dysphagia Diet Level 2: Level 2 can tolerate (most of the time) this texture as it should be the easiest to maneuver and safe to swallow. Mechanically altered food should be very small in size, soft, and with extra moisture added.Review of Resident 1's clinical record revealed diagnoses that included unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dehydration (the loss of water and salts essential for normal body function), and generalized muscle weakness. Review of Resident 1's physician's orders revealed he had an order for Regular diet, Mechanical Soft texture, Thin consistency, with a start date of September 10, 2025.Review of select facility diet guidelines revealed residents who were ordered mechanical soft diet texture were to be served a beef enchilada as their entree for lunch on October 1, 2025.Review of Resident 1's clinical record revealed a document titled Speech Therapy Evaluation & Plan of Treatment signed by Employee 3 on September 10, 2025, read, in part, Reason for Referral: Patient referred to speech therapy (ST) due to exacerbation of cognitive impairment, decreased safety awareness, decreased oral/pharyngeal function, risk for weight loss, risk of aspiration (when something swallowed enters the airway or lungs), and decreased functional activity tolerance indicating the need for ST to assess/evaluate least restrictive oral intake, develop compensatory strategies, promote safety awareness/insight and increase verbal problem solving.Review of Resident 1's Speech Therapy progress report note dated September 20, 2025, completed by Employee 3 (Speech Language Pathologist) indicated Interventions provided: Swallow Tx [treatment]: facilitation of finger foods, facilitation of small bites/sips (1/2 to 1/3 tsp), facilitation of rate control during oral intake of food/liquid presentation and modification of bolus sizes and order/method of food/liquid presentation. Pt and Caregiver Training: Instructed patient and primary caregivers in safe swallow techniques in order to facilitate improved functional abilities with 100% carryover demonstrated by primary caregivers.Review of document, titled Speech Therapy Discharge Summary, for Resident 1 and signed by Employee 3 on October 2, 2025, read, in part, Comments: Mechanical soft with ground meats, food cut into bite size pieces.facilitation of small bites/sips (1/2 to 1/3 tsp).Review of Resident 1's meal tray ticket from October 1, 2025, failed to reveal notation that his food should be cut into bite size pieces.Review of facility provided information dated October 1, 2025, revealed that Employee 1 handed Resident 1 a half of an enchilada, measuring approximately 2.5 inches (not bite size). The Resident took one bite and, despite encouraging small bites, he proceeded to put the rest of the enchilada in his mouth. Employee 1 noticed the Resident having a blank stare and he started exhibiting labored breathing. Review of the witness statement written by Employee 1 (Occupational Therapist) read, in part, on October 1, 2025, At approximately 11:40 AM, I handed resident half of a soft beef enchilada approximately 2.5 inches in size. Resident quickly pushed half of the enchilada in his mouth. I provided visual and verbal cues to instruct resident to slow down numerous times. Resident continued to push the remaining enchilada he was holding into his mouth. I noticed resident having a blank stare and starting to exhibit labored breathing while still able to speak. I instructed resident to keep coughing. Resident stated, 'I can't' I then immediately alerted Employee 2 (Licensed Practical Nurse) and Employee 3 (Speech Language Pathologist) for further assistance.Review of witness statement written by Employee 2 read, in part, I was called to the dining room for resident 'choking.' I noted he was awake and breathing with long wheezing respirations. No cyanosis (skin, lips or nails turn blue due to a lack of oxygen in your blood) noted at that time. I raised the back of the wheelchair to a full 90 degree angle with resident continuing to have air exchange. Coughed at one time and moderate amount of mucous was expectorated. Staff present encouraged him to continue to cough to which he replied in a whisper 'I can't.'During an interview with Employee 7 (Therapy Director) on October 3, 2025, at 2:56 PM, she revealed Employee 1 was working with Resident 1 to trial finger foods and self-feeding tasks, but she could not answer as to why she provided food larger than his recommended diet consistently of bite size pieces. Interview with Employee 3 on October 4, 2025, at 11:10 AM, she indicated that the Resident was on the assisted side of the dining room so that staff could assist him with eating. She indicated that assistance would include staff cutting up food, verbally cueing him to feed himself small bites, allow him time to take rest breaks as needed, and assist with feeding if unable to complete independently or with cueing. She said that if she had specific recommendations for a resident that they would be put on the resident's tray ticket, but said that staff should always be cutting up a resident's food to bite size pieces on the assisted side of the dining room. She said she had not specifically spoken to Employee 1 regarding Resident 1's diet or precautions. She said that the other Speech Language Pathologist may have, but she would not know for sure what was discussed. She said in her speculation, Employee 1 should have given the Resident a fourth of the enchilada at a time or push some of the cheese off the enchilada.Review of Resident 6 and 9's meal tray tickets from October 1, 2025, revealed direction for cut up meats.Review of Resident 8, 11, 7 and 12's meal tray tickets from October 1, 2025, revealed direction for cut up food.Review of Resident 10's meal tray ticket from October 1, 2025, revealed direction for cut food into bite size pieces.Review of Resident 13 and 14's meal tray tickets from October 1, 2025, revealed direction for cut food into small pieces.Interview with the Nursing Home Administrator (NHA) on October 6, 2025, at 2:09 PM, revealed she would expect speech therapy recommendations to be communicated properly and noted on meal tray tickets; and she would expect speech therapy recommendations to be followed. The NHA was notified of the IJ situation on October 3, 2025, at 3:12 PM, for the choking incident that occurred on October 1, 2015 and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA on October 3, 2025, and accepted at 7:28 PM. The approved plan included: Choking policy was reviewed an updated to American Heart Association Standards. All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy. All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff. Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking. All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff. Employee 7 audited all residents on current caseload immediately to ensure current speech therapy diet recommendations were being followed. Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations. Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders. Employee 7 will educate Employee 1 on following dietary orders on her next scheduled day to work October 3, 2025. Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures. All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff. All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets. RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions. Employee 12 (Dietary Manager) audited tonight's evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate. All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate. On October 4, 2025, between 7:45 AM and 8:52 AM, breakfast meal service was observed to ensure all residents received the appropriate texture diet per their physician order. The audit of dinner service on October 3, 2025, as well as the audit of breakfast service on October 4, 2025, were reviewed without concern. Staff interviews revealed the facility had re-educated staff on mechanically altered diets and the choking policy. Interviews were conducted with two registered nurses, two licensed practical nurses, four nursing assistants, two dietary employees, the dietary manager, speech therapist and occupational therapist; all were able to verbalize their role in providing appropriate diet textures. On October 4, 2025, at 11:35 AM, the Immediate Jeopardy was lifted when the action plan implementation was verified.The facility failed to communicate and follow speech therapy recommendations for bite size pieces for Resident 1, which resulted in Resident 1 choking. This failure placed nine residents that had similar diet needs at a high risk for choking and possible death and resulted in an Immediate Jeopardy situation (Resident 6, 7, 8, 9, 10, 11, 12, 13 and 14).28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a residents medication regimen was free from unnecessary psychotropic medications and failed to ensure that residents received adequate monitoring of psychotropic medications for three of five residents reviewed for unnecessary medications (Residents 41, 66, and 67). Findings include: Review of facility policy, titled Psychoactive Drug Monitoring Policy, undated, with a last review date of January 23, 2025, revealed It is the policy of the Skilled Unit of Paramount Nursing and Rehabilitation at Fayetteville, LLC. to monitor Residents who receive antidepressant, hypnotic, antianxiety, or antipsychotic medications. The purpose was identified as to evaluate the effectiveness of the medication and to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. In addition, 1) Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. 2) The continued need for the psychoactive medication is reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record. Effects of the medications are documented as a part of the care planning process. Unless medically contraindicated, periodic dosage reductions are attempted and the results documented. 6) Initiation and dosing of the psychoactive medication follows recommendations for the medical literature, clinical practice guidelines, and regulations and standards. 7) All of the following conditions are satisfied prior to initiation and/or continuation of therapy: a. Possible reversible causes for the resident's distress have been ruled out. b. Use results in maintenance or improvement in the resident's functional status. c. Long-term daily use has been accompanied by unsuccessful gradual dosage reduction. d. The need for and response to therapy are monitored and documented in the resident's medical record. Review of Resident 41's clinical record revealed diagnoses that included generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's current physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet give 2.5 mg (milligrams) by mouth two times a day; sertraline hydrochloride oral (an antidepressant medication) tablet 25 mg give one tablet by mouth at bedtime; and trazodone hydrochloride oral tablet 50 mg give one tablet by mouth at bedtime, all dated May 1, 2025. All aforementioned medications are classified as psychotropic medications (any drug that affects behavior, mood, thoughts, or perception which includes medications for anxiety and depression as well as antipsychotics). Further review of Resident 41's physician orders revealed that the Resident had been ordered a psychotropic medication since his original admission to the facility on May 9, 2024. Review of Resident 41's clinical record failed to identify side effects that staff should observe for or any documentation of ongoing side effect monitoring of his psychotropic medications. During a staff interview with the Director of Nursing (DON) and Assistant DON on June 5, 2025, at 1:01 PM, the DON indicated that side effect monitoring would be documented in progress notes as staff would only document side effect monitoring if actual side effects were noted to occur. Email communication received from the DON on June 5, 2025, at 1:11 PM, indicated We document adverse effects of all medication, not just psychotropics when side effects occur. The exception to forced documentation is with changes to particular psychotropics, and we are documenting on target symptom leading to increase/decrease etc. Review of Resident 66's clinical record revealed diagnoses that included alzheimer's disease with late onset (memory loss and cognitive difficulties that start after age [AGE]) and anxiety disorder. Review of Resident 66's physician orders revealed orders lorazepam (psychotropic medication) 2 mg/milliliter (ml) 0.5 ml every six hours as needed (PRN) for anxiety related to dementia, with a start date of February 17, 2025; and haloperidol lactate (psychotropic medication) 2 mg/ml 0.5 ml every six hours as needed for agitation/nausea related to dementia, with a start date of February 17, 2025. Further review of Resident 66's physician orders failed to include stop dates for the aforementioned medications. Additional review of Resident 66's clinical record revealed a pharmacy review dated February 26, 2025, with a recommendation to add a 14 day stop date for PRN [as needed] psychotropic medications. Further review of this document revealed the physician marked agreed and signed the form March 4, 2025, but provided no additional order for a stop date. During an interview on June 5, 2025 at 12:29 PM, with the DON, the DON stated it was the facility's expectation that PRN psychotropic medication orders have appropriate stop dates. Review of Resident 67's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included anxiety and depression. Review of Resident 67's current physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet 5 mg oral tablet 5 mg (milligrams) give one tablet by mouth three times a day dated April 8, 2025; clonazepam (an antianxiety medication) oral tablet 0.5 mg Give 0.5 tablet by mouth two times a day, dated May 15, 2025; sertraline (an antidepressant medication) 125 mg (give one 100mg tablet and one 25 mg tablet to equal 125 mg) one time a day, dated April 8, 2025; and trazodone hydrochloride (an antidepressant medication) oral tablet 50 mg give one tablet one time a day, dated May 14, 2025. All of which are classified as psychotropic medications. Review of Resident 67's physician order history revealed that she was ordered the buspirone, sertraline, and trazodone on her original admission date of February 13, 2025. Review of Resident 67's clinical record failed to include identified side effects staff should observe for or any documentation of ongoing side effect monitoring of her psychotropic medications. During a staff interview with the DON and Assistant DON on June 5, 2025, at 1:01 PM, the DON indicated that side effect monitoring would be documented in progress notes as staff would only document side effect monitoring if actual side effects were noted to occur. Email communication received from the DON on June 5, 2025, at 1:11 PM, indicated We document adverse effects of all medication, not just psychotropics when side effects occur. The exception to forced documentation is with changes to particular psychotropics, and we are documenting on target symptom leading to increase/decrease etc. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 25 residents reviewed (Residents 37, 41, and 67). Findings include: Review of Resident 37's clinical record revealed diagnoses that included cerebral infarction (death of brain tissue caused by a disruption in blood flow) and paraplegia (inability to move the lower part of the body). Review of Resident 37's quarterly minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated April 16, 2025, revealed Resident 37 was coded as receiving anticoagulant medication. Review of Resident 37's current and discontinued physician orders failed to reveal Resident 37 had been ordered anticoagulant medication. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on June 4, 2025, at 2:02 PM, it was revealed that Resident 37's quarterly MDS assessment had been coded incorrectly and a modification had been submitted. The NHA stated that it was the facility's expectation that MDS assessments be coded accurately. Review of Resident 41's clinical record revealed diagnoses that include generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's Significant Change MDS with the assessment reference date (last day of the assessment period) of February 26, 2025, indicated in Section N. Medications that he was documented as not receiving an antianxiety medication. Review of Resident 41's Medication Administration Record for February 2025 revealed that he had been administered an antianxiety medication in the assessment period. Review of Resident 41's Significant Change MDS with the assessment reference date of May 3, 2025, indicated in Section N. Medications that he was documented as receiving an anticonvulsant medication. Review of Resident 41's Medication Administration Record for April 2025 and May 2025 failed to reveal any documentation that he had been administered an anticonvulsant medication in the assessment period. During a staff interview with the DON and the Assistant Director of Nursing (ADON) on June 5, 2025, at 11:27 AM, the DON confirmed that Resident 41's MDS assessments were coded incorrectly and that he would expect MDS assessments to be an accurate reflection of a resident during the assessment reference period. Review of Resident 67's clinical record revealed diagnoses that included Parkinson's Disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and restless leg syndrome (condition that causes a very strong urge to move the legs which usually is caused by an uncomfortable feeling in the legs). Review of Resident 67's admission MDS with the assessment reference date of May 20, 2025, indicated in Section N. Medications that she was documented as not receiving an anticonvulsant medication. Review of Resident 67's Medication Administration Record for May 2025 revealed that had been administered an anticonvulsant medication in the assessment period. During a staff interview with the DON and the ADON on June 5, 2025, at 11:27 AM, the DON confirmed that Resident 67's MDS assessment was coded incorrectly and that he would expect MDS assessments to be an accurate reflection of a resident during the assessment reference period. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 18 residents reviewed (Residents 5, 41, and 66). Findings include: Review of the facility policy, titled Care Plan Policy, last reviewed January 23, 2025, read, in part, .to develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that include, but are not limited to, those identified in the comprehensive assessment . Using the initial plan of care, any updates, the comprehensive assessment and the resultant CAA investigations, the interdisciplinary team will meet with the resident and the resident's family or representative, as appropriate, and develop quantifiable objectives for the highest level of functioning the resident may be expected to attain - physically, mentally, and psychosocially. Review of Resident 5's clinical record revealed diagnoses that included major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities) and generalized anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension). Review of Resident 5's physician orders revealed an order for olanzapine (antipsychotic medication) 5 milligrams (mg) one time a day for major depressive disorder. Review of Resident 5's modification of admission minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), dated December 23, 2024, revealed Resident 5 was coded as receiving psychotropic medication. Further review of the Care Area Assessment worksheet revealed Resident 5 was triggered for psychotropic medications and would be care planned. Review of Resident 5's comprehensive care plan failed to reveal any care planning for psychotropic medication use. During a staff interview on June 5, 2025, at 12:31 PM, with the Director of Nursing (DON), the DON stated it was the expectation of the facility that comprehensive care plans be developed accurately. Review of Resident 41's clinical record revealed diagnoses that include generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet give 2.5 mg (milligrams) by mouth two times a day; sertraline hydrochloride oral (an antidepressant medication) tablet 25 mg give one tablet by mouth at bedtime; and trazodone hydrochloride oral tablet 50 mg give one tablet by mouth at bedtime all dated May 1, 2025. All of which are classified as psychotropic medications (any drug that affects behavior, mood, thoughts, or perception which includes medications for anxiety and depression as well as antipsychotics). Further review of Resident 41's physician orders revealed that he had been ordered at least one psychotropic medication since his original admission to the facility on May 9, 2024. Review of Resident 41's Significant Change MDS assessments dated on February 26, 2025, and May 3, 2025, revealed that he was coded for receiving psychotropic medications. Review of the completed Care Area Assessment worksheet for both of these assessments indicated that Resident 41 triggered for his psychotropic medication use and that this would be care planned. Review of Resident 41's current comprehensive care plan failed to reveal any documentation of his psychotropic medication use. In addition, his full care plan revision history failed to reveal any documentation of psychotropic medication use. During a staff interview with the DON and the Assistant DON on June 5, 2025, at 12:22 PM, the DON confirmed that Resident 41's psychotropic medication use should have been care planned as his two most recent assessments indicated. Review of Resident 66's clinical record revealed diagnoses that included alzheimer's disease with late onset (memory loss and cognitive difficulties that start after age [AGE]) and anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension) Review of Resident 66's physician orders revealed orders for xanax (psychotropic medication) 0.25 mg one time a day; lorazepam (psychotropic medication) 2 mg/milliliter (ml) 0.5 ml every six hours as needed; and haloperidol lactate (psychotropic medication) 2 mg/ml 0.5 ml every six hours as needed. Review of Resident 66's admission MDS dated [DATE], revealed Resident 66 was coded as receiving psychotropic medication. Further review of the care area assessment worksheet revealed Resident 66 was triggered for psychotropic medications and would be care planned. Review of Resident 66's comprehensive care plan failed to reveal any care planning for psychotropic medication use. During a staff interview on June 5, 2025, at 12:31 PM, with the DON, the DON stated it was the expectation of the facility that comprehensive care plans be developed accurately. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure urinary catheter care was completed for three of four residents reviewed with urinary catheters (Residents 1, 21, and 41). Findings include: Review of the facility policy, titled Prevention of Catheter Associated Urinary Tract Infections, last reviewed January 23, 2025, under Catheter Care section stated, daily catheter care should be documented in the resident's EHR (electronic health record). Review of Resident 1's clinical record revealed diagnoses that included obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed) and type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy). Physician orders dated August 2024 through June 2025 identified that Resident 1 had an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Physician orders also stated catheter care was to be performed daily on every shift. Review of Resident 1's Treatment Administration Record revealed no evidence that catheter care was completed by staff until September 11, 2024. During a staff interview with the DON on June 5, 2025 at 12:20 PM, the DON confirmed there was no documentation of catheter care for Resident 1. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. Review of Resident 21's clinical record revealed diagnoses that included retention of urine (a urinary tract disorder that occurs when urine flow is obstructed) and cerebral palsy (congenital disorder of movement, muscle tone, or posture). Physician orders dated February 2025 through June 2025 identified that Resident 21 had an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Physician orders also stated catheter care was to be performed daily on every shift. Review of Resident 21's care plan revealed foley catheter care to be completed every shift and as needed, effective February 20, 2025. Review of Resident 21's Treatment Administration Record revealed catheter care was not present and being signed off by staff as completed every shift. During a staff interview with the DON on June 5, 2025 at 12:20 PM, the DON confirmed there was no documentation of catheter care for Resident 21. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. Review of Resident 41's clinical record revealed diagnoses that included urinary retention and unspecified disorder of the urinary system. Review of Resident 41's physician orders revealed orders for a foley catheter 18 French 30 cc and catheter care every shift, dated May 1, 2025. Further review of Resident 41's clinical record revealed that he has had the foley catheter since his original admission to the facility on May 9, 2024. During a staff interview with the DON and the Assistant Director of Nursing on June 5, 2025, at 12:22 PM, the DON confirmed that he could not locate any documentation indicating that Resident 41 received catheter care every shift, and that he would expect catheter care to be documented every shift. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 18 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included paraplegia (inability to voluntarily move the lower parts of the body) and depression (persistent feeling of sadness, loss of interest, or both, that interferes with daily life activities). During an interview with Resident 37 on June 2, 2025 at 12:09 PM, Resident 37 revealed that at the age of 19 he was the only survivor of a plane crash. Resident 37 also revealed he was severely injured in the crash, which resulted in him being paralyzed from the waste down. Further review of Resident 37's clinical record failed to reveal documentation that any trauma screening had been done. Email communication with the Nursing Home Administrator on June 4, 2025, at 12:50 PM, revealed Resident 37 had not had a trauma screening completed. During an interview on June 5, 2025, at 12:27 PM, with the Director of Nursing (DON), it was revealed that the facility had not been completing trauma screenings and created a policy the prior day (June 4, 2025) for trauma informed care. The DON stated it was the expectation of the facility that residents be screened for trauma. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in one of one nourishment refrigerators. Findings include: Review of facility policy, titled Food Storage/Refrigerators, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 5. Foods must be stored in appropriate containers; covered, labels, and dated. 6. All food items must be stored 6 inches off the floor. Review of facility policy, titled Food Storage/Dry Storage, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 1. All foods or food items not requiring refrigeration shall be stored at least 6 inches off the floor and 18 inches from the ceiling. 2. Items must be stored on a surface, which facilitates thorough cleaning. 4. All items are stored and issued on a first in/first out rotation. All cans must be dated. 7. Any opened items must be dated with the date of opening and tightly recovered to preserve freshness. 9. Any damaged cans or cartons will be refused delivery, credited by the appropriate purveyor, or discarded. These items will be removed from the kitchen storage and placed in the Food Service Manager's office until credited. Review of facility policy, titled Identification of Food Supplies, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 1. All food supplies removed from original container must be clearly identified in storage container. 2. Labeling shall contain name of item and date container was opened. Review of facility policy, titled Personal Food/Beverage Storage with a last revised date of June 3, 2025, indicated 1. All foods/beverages will be labeled with the resident name and date when brought into the facility. 2. Outside source, for example: family, friends, etc. will be educated that unconsumed items will be discarded 3 days after the date marked. 3. Nursing is responsible for checking temperatures of refrigerator unit and safe techniques are followed regarding discarding all outdated items. Tour of the kitchen on June 2, 2025, between 9:45 AM and 10:15 AM, with Employee 1 (Dietary Manager) revealed the following observations: Walk-in cooler had a 50-pound bag of onions approximately half full sitting on floor; Ice machine vent on the outside of the upper portion was covered with a moderate amount of fuzzy gray colored debris; Three bay refrigerator had four packages of bagels with no dates indicated; Walk-in freezer had an opened package of peas and an open package of California blend vegetables with no dates indicated and a box of mixed bread items with no dates indicated on any of the packages; Dry storage had three small clear packages of a type of rice type grain with seasoning, which had no actual labeling of what the item was or any dates; an opened package of elbow noodles dated, but not secured; an opened container of ginger spice with a delivery date December 13, 2023, and no open date indicated; three packages of pork gravy mix with no dates indicated; an opened bag of shredded coconut with no dates indicated; a dented can of cherry pie filling on rack to be used; opened bag of corn flakes and and an opened bag frosted mini wheats with no open date; and two cases of potatoes and one case of oatmeal sitting directly on the floor; and Three-compartment sanitation sink had no test strips noted. During an immediate staff interview with Employee 1 on June 2, 2025, at 10:10 AM, Employee 1 indicated that the bagels in the three bay refrigerator were pulled from freezer that morning; that he was not aware items should not be stored directly on floor; that maintenance cleans the ice machine vents; that all items should be labeled, dated and securely closed; spices are good for one year after opening; and that the facility food provider had indicated dented cans can be used and should not be sent back unless there is an actual puncture or leak noted. He further indicated that he would locate the test strips for the three-compartment sink. Observation of a refrigerator in the Activity Room on June 2, 2025, at 10:16 AM, revealed the presence of a sign on the front which indicated items must be labeled with name and date and that items will be thrown away if noted to be greater than three days old. Inside the refrigerator, there was dried spills noted on the shelves, drawers, and in the bottom of the refrigerator; there were three beverages in facility cups with plastic disposable lids with no names or dates noted; and there a was chocolate dessert labeled with a resident's name dated May 24, 2025. During a staff interview with Employee 1 on June 2, 2025, at 10:21 AM, Employee 1 indicated that nursing staff was responsible for the refrigerator in the activity room. Observation in the kitchen on June 3, 2025, at 11:45 AM, revealed that two containers of test strips for the three-compartment sanitation sink were present. One was unopened with an expiration date June 2026, and the other one was opened but the insert with results grid was missing and, therefore, there was also no expiration date noted. In addition, in the walk-in cooler there was a case of canned gravy sitting directly on the floor. During a staff interview with the Nursing Home Administrator (NHA) on June 3, 2025, at 1:33 PM, the NHA indicated that she thought dietary was responsible for the activity room refrigerator, but indicated that they had just recently changed their facility practice for snacks, which means that this refrigerator was more for outside food brought in for residents. During a follow-up staff interview with the NHA and Director of Nursing on June 4, 2025, at 2:04 PM, the NHA confirmed that she would expect foods to be labeled, dated, and stored properly. She indicated that nursing was responsible for labeling and dating of foods in activity room refrigerator and that dietary would be responsible for cleaning the refrigerator. She also confirmed that the sanitation strips should have expiration date as well as testing guide. She confirmed that could not speak as to the accuracy of the testing that had been documented and, therefore, was not submitting the test logs for review. The NHA also indicated that she had identified concerns in the dietary department prior to survey and that she had made some staffing changes to improve services. 28 Pa. Code 201.18(b)(1)(3) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 18 residents reviewed (Residents 41 and 67). Findings include: Review of facility policy, titled Care Plan Policy with a last revised date of February 20, 2020, and a last review date of January 23, 2025, revealed The Care Plan will be updated on an ongoing basis by the charge nurse whenever new nursing orders are received and/or any changes in condition with the resident. Review of Resident 41's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 41's physician orders revealed an order for fluid restriction of 2000 ml (milliliters) in 24 hours. Review of Resident 41's care plan revealed in his nutrition care plan an intervention for fluid restriction 1500 ml in 24 hours, dated October 11, 2024; and in his cardiovascular care plan an intervention for fluid restriction 2000 ml in 24 hours, dated April 17, 2025. In an email communication received from the Director of Nursing on June 5, 2025, at 11:44 AM, he indicated that the care plan should have been revised when the fluid restrictions were changed. Review of Resident 67's clinical record revealed diagnoses that included Parkinson's Disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements), repeated falls, and compression fractures (a break in a vertebra [a bone in your spine] which causes the bone to collapse) to the lumbar region of her back. Review of Resident 67's clinical record revealed that she sustained a fall at the facility on April 3, 2025, which resulted in a hospital transfer on April 4, 2025, where she was identified as having a new compression fracture to the lumbar region of her back. Review of Resident 67's current care plan failed to reveal that her new fracture from her fall was included in her care plan. Further review of Resident 67's care plan revealed that she was care planned for a urinary tract infection (UTI) dated March 14, 2025. Review of Resident 67's clinical record failed to reveal any documentation that she was currently being treated for a UTI. In an email communication received from the Nursing Home Administrator on June 4, 2025, at 3:47 PM, she indicated Resident 67's fall with fracture was not added to the care plan and that the UTI from March was removed. She further indicated that she would expect the fracture to have been added to the fall care plan and the UTI removed from the care plan after resolving. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (upper chambers [atria] of the heart beat rapidly and irregularly) and congestive heart failure (condition where the heart muscle is weakened and cannot pump blood effectively). Review of Resident 1's comprehensive plan of care revealed focus areas for ADLs (activities of daily living) and falls. Further review of Resident 1's care plan failed to include an intervention that indicated Resident 1's level of assistance required for ADL care. During an in interview on March 10, 2025 at 2:15 PM, with the Director of Nursing it was revealed that assistance type and level should be indicated on the Resident's care plan. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 20 residents observed (Residents 35 and 54). Findings include: Observations of Resident 35's room on July 1, 2024, at 9:59 AM, and July 2, 2024, at 11:51 AM, revealed a pedestal fan with gray fuzzy debris on the blades and blowing from the front of the fan. Observations of Resident 54's room on July 1, 2024, at 11:18 AM, and July 2, 2024, at 11:52 AM, revealed a small fan sitting on a nightstand with gray fuzzy debris on the blades and blowing from the front of the fan. In an email communication received from the Nursing Home Administrator (NHA) on July 3, 2024, at 9:08 AM, the NHA revealed that the facility did not have a policy on the cleaning of fans. She further indicated that she had spoken to the housekeeping manager and that the cleaning of fans had now been added to the monthly resident room deep clean list. She also indicated that the housekeeping staff had cleaned all facility fans. In an interview with the NHA on July 3, 2024, at 10:54 AM, the NHA indicated that housekeeping staff was wiping down the outside of the fans and confirmed that they had no process for disassembling the fans and cleaning the blades of any debris before July 2, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent worsening of pressure ulcers for one of two residents reviewed for pressure ulcers (Resident 56). Findings include: Review of Resident 56's clinical record revealed diagnoses that included stage 4 pressure ulcer of the right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), type 2 diabetes mellitus with foot ulcer (a metabolic disorder in which the body has high sugar levels for prolonged periods of time leading to breakdown of skin and sometimes deeper tissues), and hypertension (high blood pressure). Review of Resident 56's physician orders revealed an order for Heels up when in bed, with a start date of March 29, 2024. Further review of Resident 56's physician orders revealed an order for Offloading boot to be worn in bed to RLE (right lower extremity), with a start date of April 2, 2024. Review of Resident 56's weekly wound consultation notes revealed recommendations from the wound physician initiated April 8, 2024, for Float heels while in bed, limit sitting for 60 minutes, bed cradle to keep weight of blankets off toes, elevate legs. Further review of all weekly wound consultation notes from April 8, 2024, to present revealed The clinical documentation for this consultation was made available to the referring physician. This documentation has also been made available for access to the appropriate personnel and placement in the medical record. Observations of Resident 56 in her room on July 1, 2024, at 10:35 AM, 11:18 AM, and 12:22 PM, revealed both of her feet were exposed and laying directly on her mattress. During an interview with the Director of Nursing (DON) on July 2, 2024, at 1:56 PM, the surveyor revealed the observations of Resident 56 in bed without elevated heels, no offloading boot to RLE, and no bed cradle. During a follow-up interview with the DON on July 3, 2024, at 12:59 PM, he revealed the bed cradle was implemented that morning. He further revealed the process for communicating wound physician recommendations is the facility wound nurse will communicate any recommendations from the wound physician to the facility physician to review and order, unless he disagrees. Further, he could not find any documentation to indicate the physician disagreed with the weekly recommendation for the bed cradle, dating back to April 8, 2024. During an interview with the Nursing Home Administrator on July 3, 2024, at 1:01 PM, she revealed she was unable to locate documentation to indicate Resident 56 had refused her heels up or offloading boot at the time of surveyor observations. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed (Resident 54). Findings include: Review of Resident 54'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) and muscle weakness. Review of Resident 54's physician orders revealed an order for a palm protector to the right hand due to contracture (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints), may remove for care, dated May 21, 2024. Observation of Resident 54 and their room on July 1, 2024, at 11:18 AM, revealed Resident 54's palm protector was lying on a chair in their room and that Resident 54 was in an activity with no palm protector in place. Observation of Resident 54 on July 1, 2024, at 12:46 PM, revealed that they were seated in the common area near the nurse's station with no palm protector in place. Review of Resident 54's Treatment Administration Record for May 2024, June 2024, and July 2024, failed to reveal any documentation of the application of their ordered palm protector. In an email communication received from the Nursing Home Administrator (NHA) on July 3, 2024, at 12:19 PM, the NHA indicated that they had no documentation to provide for Resident 54's palm protector application/usage since ordered on May 21, 2024. She further indicated that the facility considers a palm protector to be a splint. In an interview with the NHA and the Director of Nursing on July 3, 2024, at 12:50 PM, the NHA confirmed that staff should have been documenting the application and/or refusal of the palm protector. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing Services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 20 residents reviewed (Resident 19). Findings include: Review of facility policy, titled Fluid Restriction Policy, last revised February 12, 2022, read, in part, Purpose: To ensure that fluid restricted residents receive adequate hydration by close monitoring .Care Plans will be updated to address interventions. Review of Resident 19's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF - long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and acute upper respiratory infection. Review of Resident 19's physician orders revealed an order: Regular diet, Regular texture, Thin consistency (fluids), Fluid Restriction 2000ml (milliliter- unit of measure), with a start date of February 4, 2024. Further review of resident 19's clinical record failed to reveal notation in her care plan about her fluid restriction, or a breakdown of fluids provided between dietary and nursing each shift. Observation in Resident 19's room on July 1, 2024, at 11:20 AM, revealed a large cup on her bedside table containing approximately 120 ml of water. Review of Resident 19's dietary tray tickets from July 1, 2024, revealed she was provided 1560 ml of fluid from dietary throughout the day: 360 ml at breakfast, 720 ml at lunch, and 480 ml at dinner. Review of nurse aide task, titled Additional Fluids on July 1, 2024, revealed Resident 19 was documented as receiving 120 ml at 5:35 AM; 480 ml at 1:02 PM; 60 ml at 6:12 PM; and 120 ml at 10:47 PM. Review of nurse aide task, titled Fluids on July 1, 2024, revealed Resident 19 was documented as receiving 240 ml of fluid at 1:01 PM, 1:25 PM, 6:12 PM, and 9:59 PM. Observation in Resident 19's room on July 2, 2024, at 10:07 AM, revealed a large cup on her bedside table containing approximately 480 ml of water. Email correspondence with the Nursing Home Administrator on July 2, 2024, at 2:24 PM, the surveyor questioned the two different nurse tasks capturing fluids as well as how the facility is managing Resident 19's fluid restriction. Observation in Resident 19's room on July 3, 2024, at 09:41 AM, revealed a large cup on her bedside table containing approximately 120 ml of water. Review of nurse aide task, titled Additional Fluids on July 3, 2024, revealed Resident 19 was documented as receiving 480 ml at 9:56 AM by Employee 1 (Nurse Aide). Review of nurse aide task, titled Fluids on July 3, 2024, revealed Resident 19 was documented as receiving 240 ml of fluid at 9:56 AM by Employee 1. During an interview with Employee 1 on July 3, 2024, at 10:31 AM, he revealed he was unaware Resident 19 was on a fluid restriction, and that he does not provide additional fluids to Resident 19, he only documents what is provided from dietary. During an interview with the Director of Nursing (DON) on July 3, 2024, at 10:59 AM, he revealed nurse aides document the fluids from dietary under fluids, and fluids provided by nursing, including fluids provided during medication pass, under additional fluids. Further, the DON stated that Employee 1 might not know about Resident 19's fluid restriction as he is a fairly new employee. During a follow up interview with the DON on July 3, 2024, at 1:18 PM, the surveyor revealed the concern with the overall management and monitoring of Resident 19's fluid restriction. No further information was provided. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV - tube inserted into a vein, which medication is administered through) therapy for two of two residents receiving IV medications (Residents 64 and 326). Findings Include: Facility policy, titled 13.6 Medication Administration Guidelines: Specific, effective date October 1, 2018, stated in part, 7. Compare the MAR (medication administration record) with the medication label for accuracy and note the following: A. Incorrect label or direction change by the health care provider .D. If the label and MAR differ for any other reason or if there are questions about the dosage or directions, do not administer the medication. Contact pharmacy provider. Review of Resident 64's clinical record revealed diagnoses that included osteomyelitis (infection of a bone) of the lumbar (lower back) region and discitis (an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). Review of Resident 64's current physician orders revealed an order for Meropenem intravenous (IV) solution reconstituted administer one gram intravenously three times a day related to osteomyelitis of vertebra, dated June 17, 2024. During an interview with Resident 64 on July 1, 2024, at 9:53 AM, it was observed that an empty medication solution bag of Meropenem was hanging on an IV pole, the IV tubing was not dated, and the end of the IV tubing was secured into a port on the IV tubing. Observation also revealed a sheet of IV line end caps to be present hanging on the intravenous pole near the empty medication solution bag. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 3, 2024, at 10:55 AM, the DON confirmed that Resident 64's IV tubing should have been properly dated and capped. Review of Resident 326's clinical record revealed diagnoses that included: bacteremia (bacteria in the blood) and excoriation disorder (a mental illness related to obsessive-compulsive disorder characterized by repeated picking at the skin). Review of Resident 326's physician orders revealed an order for daptomycin 500 mg intravenously one time a day for infection. Review of Resident 326's medication administration record for July revealed daptomycin 500 mg documented as administered at 5:00 AM on July 1, 2024. During the initial tour of the facility on July 1, 2024 at 10:44 AM, an observation of Resident 326 was completed, which revealed an IV medication bag hanging on an IV pole at Resident 326's bedside. At the time of the observation, Resident 326 revealed that she had an infection and had received IV antibiotics earlier that morning. Further observation of the IV setup revealed an IV medication bag with a pharmacy label showing daptomycin (antibiotic medication) 500 milligrams (mg) per 100 milliliters (ml) of normal sterile saline with another resident's name on the label, the IV tubing end was connected into one of the ports on the tubing, and no date was observed on the tubing. During a staff interview on July 1, 2024 at 10:56 AM, with Employee 3 (Licensed Practical Nurse), it was revealed that the night shift registered nurse was responsible for hanging IV medications. During an additional staff interview on July 1, 2024 at 11:00 AM, with Employee 2 (Registered Nurse Supervisor), it was revealed that the bag of IV medication was the correct medication, but was for another resident. Employee 2 stated the IV tubing should have been dated and that the tubing should have been capped, not connected to itself. Employee 2 removed the IV medication bag and tubing from Resident 326's room. During a staff interview on July 3, 2024, with the NHA and the DON, the DON revealed it was the expectation of the facility that residents be free from medication errors, IV tubing be dated, and IV tubing be capped when not in use. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain oxygen equipment in a sanitary manner and provide respiratory care consistent will professional standards for one of 20 residents reviewed for oxygen (Resident 19). Findings include: Review of facility policy, titled Oxygen Therapy Policy, last revised April 4, 2018, read, in part, Oxygen tubing will be dated and changed bi-weekly by the 11-7 Licensed Staff. Review of Resident 19's clinical record revealed diagnoses that included Covid-19 (respiratory virus), shortness of breath (uncomfortable feeling of not being able to breathe well enough), and muscle weakness. Observation of Resident 19's oxygen tubing on July 1, 2024, at 11:20 AM, revealed her oxygen tubing was dated June 2, 2024. Observation of Resident 19's oxygen tubing on July 2, 2024, at 10:07 AM, revealed her oxygen tubing was dated June 2, 2024. Review of Resident 19's clinical record revealed she tested positive for Covid-19 infection on June 20, 2024. During an interview with the Director of Nursing (DON) on July 2, 2024, at 10:42 AM, the surveyor revealed the observations of Resident 19's oxygen tubing dated June 2, 2024. Follow-up interview with the DON on July 2, 2024, at 1:56 PM, he revealed the tubing was not changed bi-weekly since June 2, 2024, due to the Resident being asleep and refused when awakened. The surveyor inquired if staff reapproached at a later time or documented the refusals. Observation of Resident 19's oxygen tubing on July 3, 2024, at 9:41 AM, revealed her oxygen tubing was dated July 1, 2024. Interview with Resident 19 on July 3, 2024, at 9:42 AM, revealed the nursing staff came in and changed her oxygen tubing the previous afternoon. Interview with the DON on July 3, 2024, at 10:59 AM, revealed he would expect staff to reapproach about tubing change, document refusal of the tubing change, and that they would follow-up about the wrong date on the new tubing as it was changed on July 2, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that 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 two of four residents reviewed (Residents 52 and 326). Findings include: Review of facility policy, titled Isolation Precaution Policy, with a last revised date of July 25, 2023, and a last reviewed date of January 25, 2024, revealed, in part, 1. This facility will follow CDC (Center for Disease Control) guidelines when determining what form of isolation precautions will be instituted i.e., Contact, Respiratory, or Enhanced Barrier Precautions; 2) Isolation precautions will be initiated by a physician's order and or deemed necessary by nursing judgment; and 5) A sign will be placed on the resident's door to alert staff and visitors. Review of facility policy, titled Shingles, with a last revised date of June 20, 2017, and a last reviewed date of January 25, 2024, defined shingles as a painful blistering skin rash due to the varicella-zoster virus, the virus that causes chickenpox; and that the virus will be prevented from transmission to residents and employees within the facility. Review of facility policy, titled Infection Control Enhanced Barrier Precaution Paramount Skilled Nursing and Rehabilitation Facilities, last revised April 1, 2024, revealed Policy Statement - All employees will utilize Enhanced Barrier Precaution for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Implementation 1. For Enhanced Barrier Precautions, signage should clearly indicate the high-contact resident care activities that require use of gown and gloves. 2. Make PPE (personal protective equipment), including gowns and gloves, available immediately outside of the resident room. Review of the Center for Disease Control 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, with a last revised date of September 2018, revealed that Contact Precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment; that Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission; and that someone diagnosed with shingles should remain under contact precautions until lesions are dry and crusted. Review of Resident 52's clinical record revealed diagnoses that included herpes zoster (shingles) and mild cognitive impairment. Review of Resident 52's current physician orders revealed an order for Acyclovir Oral Tablet 400 MG (an antiviral medication used to treat shingles) give one tablet by mouth three times a day related to herpes zoster for 10 days, dated June 24, 2024, and end date of July 4, 2024. The physician orders failed to reveal any orders regarding contact precautions. Further review of Resident 52's past physician orders history revealed that Resident 52 was originally ordered the Acyclovir and contact precautions on June 14, 2024, for 10 days. Observation of Resident of Resident 52's room on July 1, 2024, at 11:56 AM, revealed the presence of a sign that said to see the nurse before entering the room. Immediate interview with a staff nurse revealed that Resident 52 had a diagnosis of shingles and that the Resident was on contact precautions. Observation of Resident 52's room on July 1, 2024, at 12:40 PM, revealed that the aforementioned sign had been removed. Observation of Resident 52's room on July 2, 2024, at 9:47 AM, again revealed no sign was present regarding isolation precautions. Review of Resident 52's clinical record progress notes failed to reveal any nurse's notes between June 28, 2024, and July 2, 2024, that described Resident 52's shingles rash. Review of nurse's note dated July 2, 2024, at 3:00 PM, indicated Acyclovir continues for shingles rash. C/O (complaint of) pain in area with relief noted after Tylenol. Review of order note dated July 2, 2024, at 4:33 PM, indicated Resident 52's physician had followed up with resident at this time for evaluation of shingles as resident now has peripheral edema left upper thigh, and that a new order was given to restart contact isolation for shingles rash for 10 days. During an interview with the Director of Nursing (DON) on July 3, 2024, at 9:44 AM, the DON indicated that the staff followed the MD order for 10 days of precautions, which was ordered on June 14, 2024; however, he confirmed that precautions should have been continued while Resident 52 was actively being treated or, at the very least, staff should have followed up with the MD for further guidance. During a follow-up interview with the Nursing Home Administrator (NHA) and DON on July 3, 2024, at 10:55 AM, the DON indicated that Resident 52 was restarted on contact precautions on July 2, 2024, and that a new area of shingles had been identified. He again confirmed that Resident 52's contact precautions should have continued or that their physician should have been notified for guidance on precautions since they were actively being treated for ongoing shingles. Review of Resident 326's clinical record revealed diagnoses that included bacteremia (bacteria in the blood) and excoriation disorder (a mental illness related to obsessive-compulsive disorder characterized by repeated picking at the skin). Review of Resident 326's physician orders revealed an order dated June 30, 2024, that read this Resident is on EBP (enhanced barrier precautions), use gown and gloves for high-contact care activities, such as dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, every shift. Review of Resident 326's care plan revealed a focus area for enhanced barrier precautions: mid line IV (intravenous line) with an intervention for EBP sign on door/isolation bin outside of room. Observations of Resident 326's room on July 1, 2024, at 10:44 AM, and July 2, 2024, at 8:24 AM, failed to reveal signage for EBP or a PPE caddy. During a staff interview on July 3, 2024 at 10:55 AM, with the NHA and DON, it was revealed that Resident 326 should have been placed on EBP at the time of the physician's order and it is the expectation of the facility that EBP be followed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 48 resident rooms (Resident 33, 36, 37, 39, 51, and 53 rooms). Findings include: Observation in Resident 36's room on August 7, 2023, at 11:19 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 36's room on August 8, 2023, at 10:49 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 53's room on August 7, 2023, at 11:25 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 53's room on August 8, 2023, at 9:46 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 39's room on August 7, 2023, at 11:39 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 39's room on August 9, 2023, at 11:41 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 37's room on August 7, 2023, at 11:46 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 37's room on August 8, 2023, at 12:25 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 51's room on August 7, 2023, at 11:51 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 51's room on August 8, 2023, at 12:31 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 33's room on August 7, 2023, at 1:14 PM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 33's room on August 8, 2023, at 12:27 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Interview with Employee 4 (Maintenance Director) on August 9, 2023, at 09:36 AM, revealed there is no cleaning schedule or record for cleaning heaters in skilled nursing. Employee 4 further revealed the heaters in skilled nursing have not been formally cleaned to his knowledge since he has worked at the facility, and he has worked at the facility for three years. Interview with Nursing Home Administrator on August 10, 2023, at 10:39 AM, revealed she would expect the heaters to be clean and a cleaning schedule to be in place. 28 Pa. Code 201.18(e)(2.1) Management

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for one of 21 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, cerebral infarction (or stroke; when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and hypertension (high blood pressure). Interview with Resident 37 on August 7, 2023, at 11:44 AM, revealed he had a stroke with right sided weakness and needs assistance with turning and repositioning in bed. Resident 37 also revealed that he only gets turned and repositioned if he rings his call bell and asks to be turned and repositioned. Resident 37's Significant Change Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an assessment reference date (last day of assessment period) of May 22, 2023, revealed that section G0100. Activities of Daily Living (ADL) Assistance, subsection, A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, Resident 37 was coded as, 3 = Extensive Assistance under performance with Two + persons physical assist under support. Review of Resident 37's nursing tasks revealed a restorative nursing program for Bed Mobility - [Resident 37] will maintain proper bed positioning by turning and repositioning q (q-every) two hours; left side to right side to back with staff assistance x15 minutes daily to remain free of skin breakdown, initiated March 29, 2022, and last revised March 11, 2023. Review of Resident 37's care plan revealed a focus area: [Resident 37] requires assistance with ADL's related to decreased mobility, weakness, and Parkinson's disease, last revised December 20, 2021, with an intervention for: Restorative Nursing Program as ordered, created on March 12, 2023. Review of the clinical record revealed no documentation that Resident 37's restorative program for turning and repositioning every two hours was being implemented. Interview with the Director of Nursing on August 10, 2023, at 10:37 AM, revealed there is no documentation to indicate Resident 37's restorative nursing program for turning and repositioning every two hours was being implemented, and the expectation is for the restorative nursing program to be completed and documented. 28 Pa. Code 211.11 (a) Resident care plan 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services