Every finding on record at Patriot Village

Based on review of the Pennsylvania Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to follow physician's orders to hold blood thinner and anticoagulant medications prior to a scheduled surgical procedure resulting in delayed surgery for one of seven residents reviewed (Resident 7). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 7, dated June 4, 2026, indicated that the resident was cognitively intact, required set up assistance to supervision with most care needs, received an anticoagulant (medication that thins the blood) and antiplatelet (medication that prevents blood clots) medication and had a diagnosis of breast cancer. Physician's orders for Resident 7, dated December 14, 2023, included orders for the resident to receive 5 milligrams (mg) of Eliquis (an anticoagulant medication) twice daily . Physician's orders for Resident 7, dated May 2, 2025, included orders for the resident to receive 75 mg of Plavix (an antiplatelet medication) daily. A surgical consult note for Resident 7, dated June 10, 2026, revealed that the resident was scheduled for a partial mastectomy (removes only the cancerous tumor and a surrounding margin of healthy tissue) on July 10, 2026. A physician's note for Resident 7, dated June 11, 2026, revealed that the resident was seen by the physician for follow-up and pre-operative medical evaluation for a planned right breast surgical intervention in the setting of recently diagnosed invasive breast carcinoma (cancer). She was medically cleared to proceed with planned surgical intervention from a medical standpoint with orders to hold the resident's Eliquis and Plavix five days prior to the procedure. A nursing note for Resident 7, dated July 8, 2026, at 6:30 p.m. a nurse practitioner called from cardiology called to confirm the resident was cleared for surgery on Friday. The nurse practitioner verified that he would be sending the surgical center the information as well with the clearance. A nursing note for Resident 7, dated July 9, 2026, at 10:27 a.m. revealed that the resident was scheduled for breast surgery on July 14, 2026, and new orders were received to hold the resident's Plavix and Eliquis starting today. Interview with Resident 7 on July 9, 2026, at 11:42 a.m. revealed that the resident was scheduled for surgery tomorrow for a lumpectomy for breast cancer. She indicated that she had waited six months for this appointment and it was canceled because they did not hold her Eliquis and Plavix. She indicated that the nurse gave her Eliquis this morning and she told the nurse she was not supposed to get the medication, and it was to be held due to her surgery that was scheduled on Friday, July 10, 2026. The nurse told her it was not listed on the Medication Administration Record (MAR) to hold the medications. She stated that now her surgery was rescheduled for next Tuesday, July 14, 2026. The resident stated , I just want the cancer out of me and now I have to wait longer. Interview with Licensed Practical Nurse 1 on July 9, 2026, at 12:34 p.m. confirmed that there were orders in her chart now to hold her Eliquis and Plavix and she held it this morning. She stated that the resident's surgery was changed, and she does not know why. Review of the Resident 7's MAR for July 2026, revealed that the resident received her Eliquis and Plavix from July 1 through July 8, 2026. There was no documented evidence that the orders were transcribed to hold the resident's Eliquis and Plavix for the five days prior to the scheduled surgery on July 10, 2026. Interview with the Director of Nursing on July 9, 2026, at 2:52 p.m. confirmed that Resident 7's Eliquis and Plavix should have been held five days prior to her scheduled surgery on July 10, 2026, as ordered by the physician on June 11, 2026, and they were not. She confirmed that the surgery had to be rescheduled due to the medications not being held. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 36 residents reviewed (Resident 23). Findings include: A comprehensive significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated December 13, 2025, revealed that the resident was cognitively impaired, required assistance with daily care needs, received hypoglycemic medications including insulin and had a diagnosis of diabetes. Physician's orders for Resident 23, dated December 18, 2025, included orders for the resident to receive accu checks (a test used to monitor blood sugar) twice daily due to the patient receiving lantus insulin (a long-acting insulin used to lower blood sugar levels), with instructions to document if the patient refused. A review of Resident 23's December 2025 Medication Administration Record (MAR) revealed that she did not have any orders for accu checks entered into the electronic health record system for December 18, 2025. A medication entry audit revealed that the orders for Resident 23's accu checks were created by the Registered Nurse (RN) on December 18, 2025, at 7:46 a.m. as a standard order so it did not appear on the MAR to be recorded. The order was confirmed by and revised by the same RN on December 18, 2025, at 7:46 a.m. Physician's orders for Resident 23, dated December 24, 2025, included orders for the resident to receive accu checks twice daily for a diagnosis of diabetes. A review of Resident 23's December 2025 MAR revealed that she did not have any orders for accu checks entered into the electronic health record system for December 24, 2025, until January 5, 2026. A medication entry audit revealed that the orders for Resident 23's accu checks were created by the Nurse Practitioner (NP) as a standard order on December 24, 2025, at 10:12 a.m., so it did not appear on the MAR to be recorded. The order for the accu checks was confirmed by the RN on December 24, 2025, at 10:54 a.m. and revised by the Director of Nursing on January 5, 2026, at 12:47 p.m. There was no documented evidence that Resident 23's accu checks were completed as ordered from December 18, 2025, through January 4, 2026. Interview with the Director of Nursing on January 8, 2026, at 10:01 a.m. and 12:13 p.m. confirmed that Resident 23's orders for the accu checks were entered by the NP as a standard order which would not populate on the MAR for the nurses to complete. She indicated that the nurse confirming the orders do not check that the order was entered for accuracy; they only activate it. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a long-term intravenous catheter and a midline catheter (a type of peripheral catheter inserted into a large vein in the upper arm used to deliver fluids and/or medications) were flushed prior to and/or after medication administration for two of 36 residents reviewed (Residents 4, 10).Findings include: The facility's policy regarding peripheral and midline IV catheter flushing dated December 31, 2025, included flushing before and after medication or fluid administration by attaching a prefilled saline syringe to the needleless access device to ensure the entire dose of the medication is administered.A significant change Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 18, 2025, revealed that the resident was cognitively intact, had an amputation, received intravenous antibiotics, and had intravenous access.Physician's orders for Resident 4, dated October 22, 2025, included an order for the resident to receive 500 milligrams (mg) of Meropenem Intravenous solution (an antibiotic medication) intravenously every twelve hours for osteomyelitis (bone infection) until November 26, 2025.Review of the Medication Administration Record (MAR) for Resident 4 for October 2025, revealed that staff documented administering the 500 mg of Meropenem solution intravenously from October 23 though 30, 2025 at 7:30 a.m. and 7:30 p.m. However, there was no documented evidence that staff flushed Resident 4's peripheral IV before and after the administration of the Meropenem solution.Physician's orders for Resident 4, dated November 11, 2025, included an order for the resident to receive one gram of Meropenem Intravenous solution intravenously every eight hours for an amputation related to osteomyelitis of the left ankle and foot until December 11, 2025. Review of the MAR for Resident 4 for November 2025, revealed that staff documented administering the one gram of Meropenem Intravenous solution intravenously from November 11 through 24, 2025 at 6:30 a.m., 2:30 p.m., and 10:30 p.m. However, there was no documented evidence that staff flushed Resident 4's peripheral IV before and after the administration of the Meropenem solution.Interview with the Director of Nursing on January 7, 2026, at 2:26 p.m. confirmed that there was no documented evidence that Resident 4's peripheral IV was flushed before and after the administration of the Meropenem, on the dates mentioned above per the facility policy. A significant change MDS assessment for Resident 10, dated December 25, 2025, revealed that the resident was cognitively intact, and was dependent on staff for her daily care needs. Physician's orders for Resident 10, dated January 2, 2026, included an order for the resident to have a midline catheter placed for the administration of 1 gram (gm) of Invanz (an antibiotic) intravenously one time a day for seven days for a urinary tract infection. There was no documented evidence that Resident 10's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration. Review of Resident 10's Medication Administration Record (MAR), dated January 2026, revealed that staff administered one gm of Invanz intravenously on January 2, 3 and 4, 2026, at 7:30 p.m. There was no documented evidence that Resident 10's midline was flushed with saline prior to and/or after administration of the Invanz. Interview with the Director of Nursing on January 6, at 2:37 p.m. confirmed that there was no documented evidence that Resident 10's midline was flushed with saline prior to and/or after the Invanz administration on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the facility's nursing staff for one of 36 residents reviewed (Resident 6). Findings include:The facility's policy regarding dialysis (mechanical cleansing of the blood to remove waste products when the kidneys are not functioning properly), dated December 31, 2025, indicated that The facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice. This would include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The licensed nurse would communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that would include, but not limit itself to: timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; physician/treatment orders, laboratory values, and vital signs; advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; changes and/or declines in condition unrelated to dialysis; and the occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2025, revealed that the resident was understood and could understand, and had diagnoses that included end-stage renal disease (the last stage of chronic kidney disease, where the kidneys are only functioning at 10 to 15 percent of their normal capacity). The resident's care plan, dated May 23, 2024, revealed that the resident received dialysis on Monday and Friday, and prior to leaving, staff were to complete the dialysis communication form. Physician's orders, dated June 23, 2025, included orders for the resident to receive dialysis on Monday and Friday. There was no documented evidence of routine collaboration of care and communication between the long-term care facility and the dialysis center, when the resident received dialysis services on November 10, 21, 24, and 28, December 5, 15, 19, 29, 2025, and January 5, 2026. Interview with the Director of Nursing on January 8, 2026, at 2:08 p.m. confirmed that there was no documented evidence that a communication form was completed by the facility and/or dialysis center on the dates mentioned above.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that food was stored under sanitary conditions. Findings include: The facility's policy for food storage, dated December 31, 2025, indicated that frozen and refrigerated food items will be appropriately stored in accordance with guidelines of the FDA food code. The Dining Services Director/cook(s) ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observations in the main kitchen walk in refrigerator on January 5, 2026, at 9:19 a.m. revealed that there was a bag of hamburger patties that were opened and exposed to air and not dated, and observations of an opened cottage cheese container that was dated with a use-by date of January 3, 2026. Interview with the Dietary Manager at the time of the observation confirmed that the hamburger patties should have been dated when opened, sealed and not exposed to air and the cottage cheese should have been discarded. 28 Pa. Code 211.6(f) Dietary services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a comprehensive significant change Minimum Data Set assessment was completed in the required time frame for one of 36 residents reviewed (Resident 1), and failed to complete a significant change Minimum Data Set assessments for one of 36 residents reviewed (Residents 91). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the Assessment Reference Date (ARD) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days). Physician's orders for Resident 1, dated June 3, 2025, included an order for the resident to be admitted to hospice June 3, 2025, with a primary diagnosis of Hypertensive Heart Disease. A significant change Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) for Resident 1, dated June 4, 2025, revealed that the MDS was documented in section Z0500B as being completed on June 18, 2025, which was two days late. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 7, 2026, at 2:11 p.m. confirmed that the significant change comprehensive MDS assessment for Resident 1 should have been completed by June 16, 2025, and it was not. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments, dated October 2025, revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. The RAI Manual revealed that staff should complete a significant change MDS when a resident has a decline that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the resident's care plan. The RAI Manual revealed that staff should complete a significant change MDS when a terminally ill resident enrolls in a hospice program (Medicare-certified or state-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. A admission MDS assessment for Resident 91, dated October 6, 2025, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses that included heart disease with heart failure. Physician's orders for Resident 91, dated October 30, 2025, included orders to admit the resident to hospice for a diagnosis of heart disease with heart failure. There was no documented evidence in Resident 91's clinical record to indicate that a significant change MDS was completed per the RAI manual. An interview with the Director of Nursing on January 8, 2025, at 3:00 p.m., confirmed that a significant change MDS should have been completed for Resident 91. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing services. -------

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 36 residents reviewed (Residents 6, 34, 86). Findings include:The Long-Term Care Facility RAI User's Manual, dated October 2025, revealed that Section O0110J1b was to be checked if the resident was receiving dialysis treatment while a resident at the facility during the past 14 days.A care plan for Resident 6, dated May 23, 2024, revealed that the resident received dialysis on Monday and Friday, and prior to leaving, staff were to complete the dialysis communication form. Physician's orders, dated June 23, 2025, included orders for the resident to receive dialysis on Monday and Friday.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2025, revealed that the resident was understood and could understand, and had diagnoses that included end-stage renal disease (the last stage of chronic kidney disease, where the kidneys are only functioning at 10 to 15 percent of their normal capacity).However, section O0110J1b was not checked, indicating that the resident did not receive dialysis treatment while a resident in the facility during the past 14 days.Interview with the Registered Nurse Assessment Coordinator (RNAC- responsible for completing MDS assessments) on January 7, 2026, at 1:31 p.m. confirmed that section O0110J1b of Resident 6's quarterly MDS assessment, dated December 12, 3025, was not checked to indicate that the resident was receiving dialysis treatments while a resident at the facility during the past 14 days and it should have been. The RAI User's Manual, dated October 2024, indicated that Section O0110K1 Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be coded to indicate if the resident was receiving hospice services (a) on admission, (b) while a resident or (c) at discharge. Physician's orders for Resident 34, dated April 28, 2025, included an order for the resident to receive hospice services from UPMC Family Hospice, related to a diagnosis of Alzheimer disease. Review of Resident 34's clinical record, including physician's orders, care plans and nurses' notes, revealed documented evidence that the resident was receiving hospice services during the seven-day look-back period; however, a quarterly MDS assessment for Resident 34, dated October 14, 2025, revealed that Section 0O110K1 was coded no (0) while a resident, indicating that the resident was not receiving hospice services during the seven-day look back-period. Interview with the RNAC on January 6, 2026, at 1:40 p.m. confirmed that Resident 34's MDS, dated [DATE], was coded inaccurately. The RAI User's Manual, dated October 2025, revealed that Section N0410F1 (Antibiotic Medications) was to be checked if the resident received an antibiotic medication during the seven-day assessment period. Physician's orders for Resident 86, dated November 3, 2025, included an order for the resident to have Bacitracin (antibiotic ointment) applied to his suprapubic catheter (medical device used to drain urine from the bladder through a small incision in the abdomen) site, daily and as needed every day shift for suprapubic catheter care.The resident's Treatment Administration Records (TAR's) for December 2025 revealed that the resident received Bacitracin daily to his suprapubic catheter site during the seven day look-back period.A quarterly MDS assessment for Resident 86, dated December 8, 2025, revealed that Section N0410F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period.Interview with the RNAC on January 7, 2026, at 1:31 p.m. confirmed that section N0410F1 of Resident 86's quarterly MDS assessment, dated December 8, 3025, was not checked to indicate that the resident received an antibiotic during the seven day look back period.28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 36 residents reviewed (Resident 40). Findings include: A facility policy for Care Plans, dated December 31, 2025, indicated that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 40, dated October 14, 2025, revealed that the resident was severely cognitively impaired, had clear speech, sometimes understood and sometimes understands requires moderate assistance from staff with daily care tasks, and had diagnoses that included vascular dementia, anxiety and psychotic mood disturbances.Physician's orders for Resident 40, dated October 23, 2025, included orders for the resident to receive 25 milligrams of Seroquel (an antipsychotic) two times a day for psychosis (a state where a person loses touch with reality, experiencing symptoms like hallucinations and confused thinking) related to vascular dementia.There was no documented evidence that a care plan was developed to address Resident 40's individual care and treatment needs related to the use of her antipsychotic medication.Interview with the Director of Nursing on January 8, 2026, at 1:31 p.m., confirmed that a care plan to address the care needs related to Resident 40's need for antipsychotic medication was not developed, and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 36 residents reviewed (Residents 2, 5). Findings include:The facility's policy regarding care plan revision, dated December 31, 2025, indicated that nursing staff and/or the interdisciplinary team were to initiate and/or update care plans for the resident as warranted. In addition, individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated December 3, 2025, indicated that the resident was cognitively intact and did not receive a diuretic (water pill) medication during the seven day look back period. A care plan for Resident 2, dated September 15, 2025, indicated that the resident was at risk for dehydration due to receiving a diuretic medication.A review of Resident 2's Medication Administration Record (MAR) for December 2025 and January 2026 revealed no documentation that the resident received a diuretic medication. There was no documented evidence to indicate the care plan was updated to reflect the discontinuation of the diuretic medication.A significant change MDS assessment for Resident 5 dated September 12, 2025, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, sometimes understood, sometimes understands, had unclear speech and had diagnoses that included post-traumatic stress disorder (PTSD) ( a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event, leading to intrusive memories (flashbacks, nightmares), negative mood changes (guilt, fear), and heightened arousal (hypervigilance, irritability) that significantly disrupt daily life).Interview with the Social Services Director on January 7, 2026 at 11:10 a.m., indicated that Resident 5 was in the military and suffered from PTSD. She stated his triggers are loud noises and being around too many people. She indicated that she did not include his triggers on the care plan, and in retrospect she should have.Interview with the Director of Nursing on January 7, 2026, at 1:30 p.m. confirmed that Resident 2's care plan was not updated to reflect the discontinuation of her diuretic medication, and Resident 5's care plan was not updated to reflect the triggers associated with his diagnosis of post-traumatic stress disorder, and they should have been.28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 36 residents reviewed (Resident 1). Findings include: The facility's policy regarding assistive devices and equipment dated December 31, 2025, revealed that the facility maintains and supervises the use of assistive devices and equipment for residents and that if a resident is to be pushed or transported by anyone (staff, family, volunteers) in a wheelchair, bilateral leg rests must be attached to the wheelchair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 3, 2025, revealed that the resident was cognitively impaired, dependent on staff for daily care needs and a wheelchair was used as a mobility device. Observation on January 5, 2026, at 11:48 a.m. revealed that the resident was transported in her wheelchair by Nurse Aide 1 down the hallway to the dining room without the use of leg rests. Interview with Nurse Aide 1 at the time of the observation revealed that the leg rests were in a bag on the back of the wheelchair and she did not apply them to Resident 1's chair prior to transporting the resident and she should have. An interview with the Director of Nursing on January 6, 2026, at 2:37 p.m. confirmed that leg rests should have been in place prior to transporting Resident 1 to the dining room. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 36 residents reviewed (Resident 3).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 17, 2025, revealed that the resident was cognitively intact, was independent for most care needs, and had a diagnosis of osteoporosis. Physician's orders for Resident 3, dated November 16, 2025, included orders for the resident to receive 70 milligrams (mg) of Alendronate Sodium (Fosamax) daily every Sunday for osteoporosis. A pharmacy medication regimen note for Resident 3, dated November 11, 2025, indicated that the resident is receiving Fosamax which comes with very specific administration instructions. The pharmacist's recommendations indicated to update the current order to include instructions to administer the medication on an empty stomach before a.m. meals and medications, with water only (at least 8 ounces), and for the resident to remain upright for at least 30 minutes after administration. The physician signed that he agreed with the recommendations on December 2, 2025. There was no documented evidence in the resident's clinical record that the order was updated to reflect the recommendations from the pharmacist. A pharmacy medication regimen note for Resident 3, dated December 23, 2025, indicated that the resident is receiving Fosamax which comes with very specific administration instructions. The pharmacist's recommendations indicated to update the current order to include instructions to administer the medication on an empty stomach before a.m. meals and medications, with water only (at least 8 ounces), and for the resident to remain upright for at least 30 minutes after administration. The physician signed that he agreed with the recommendations on December 23, 2025. There was no documented evidence in the resident's clinical record that the order was updated to reflect the recommendations from the pharmacist. An interview with the Director of Nursing on January 6, 2026, at 12:06 p.m. confirmed that Resident 3's order for Fosamax was not updated to reflect the pharmacist's recommendations as agreed on by the physician. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:.The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending January 9, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 8, 2026, identified repeated deficiencies related to accuracy of MDS ( Minimum Data Sets) assessments, revision of residents' care plans, quality of care, and food stored, prepared and served in a sanitary manner.The facility's plan of corrections for deficiencies regarding accuracy of MDS assessments cited during the survey ending January 9, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of MDS assessments.The facility's plan of correction for deficiencies regarding revising residents' care plans, cited during the survey ending January 9, 2025, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans. The facility's plan of corrections for deficiencies regarding quality of care, cited during the survey ending January 8, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency regarding food procurement, store/prepare/serve-sanitary cited during the survey ending January 9, 2025, revealed that food procurement, store/prepare/serve-sanitary would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with regulation food procurement, store/prepare/serve-sanitary. Refer to F641, F657, F684, and F812. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for five of 31 residents reviewed (Residents 46, 54, 65, 73, 77). Findings include: A facility policy regarding plans of care, dated August 28, 2024, indicated that resident assessments are ongoing and care plans are revised as information about the resident and their condition changes. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). An annual MDS assessment for Resident 46, dated October 17, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, and was dependent with bed mobility, transfers, and lower body dressing. Resident 46's current care plan indicated that she was receiving active range of motion to her bilateral lower extremities. A physical therapy note for Resident 46, dated December 18, 2024, revealed that the resident was referred to physical therapy due to a decline in her lower extremity strength and mobility, as well as to develop an updated restorative nursing program (program developed to maintain or improve the ability to perform activities of daily living). Review of Resident 46's restorative nursing documentation for December 2024 revealed that the resident's active range of motion (the ability to move a joint or muscle using your own strength without any assistance) restorative nursing program to her bilateral lower extremities was stopped on December 18, 2024. Interview with the Director of Nursing on January 9, 2025, at 10:39 a.m. confirmed that Resident 46's care plan was not revised to reflect that the active range of motion restorative nursing program to her bilateral lower extremities was stopped on December 18, 2024. An annual MDS assessment for Resident 54, dated December 11, 2024, indicated that the resident was cognitively impaired and had diagnoses that included anxiety (an emotion that can feel like dread or fear in the face of an anticipated threat). An active care plan for Resident 54 indicated that the resident was receiving an anti-anxiety medication. Review of Resident 54's Medication Administration Record (MAR) for January 2025 and review of her current physician's orders revealed that the resident was not ordered to have an anti-anxiety medication. Interview with the Director of Nursing on January 8, 2025, at 2:19 p.m. confirmed that Resident 54's care plan was not revised to reflect that her anti-anxiety medication had been discontinued. An admission MDS assessment for Resident 65, dated December 1, 2024, indicated that the resident was cognitively intact and had diagnoses that included urinary retention (condition that makes it difficult or impossible to empty the bladder). Physician's orders for Resident 65, dated December 26, 2024, included an order for a catheter to be placed in the resident. Review of Resident 65's care plan indicated that the resident had bladder incontinence (involuntary loss of urine) related to impaired mobility. Interventions included cleaning the resident after any incontinent episodes and toileting the resident everyday after lunch. Interview with the Registered Nurse Assessment Coordinator (RNAC - a nurse who initiates and updates the resident's plan of care) on January 8, 2025, at 12:32 p.m. confirmed that Resident 65 had a catheter placed on December 26, 2024; therefore the resident's care plan regarding bladder incontinence no longer applied to the resident and should have been removed, and it was not. A quarterly MDS assessment for Resident 73, dated November 21, 2024, revealed that the resident was understood, could understand others, had diagnoses that included end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and received dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). A care plan for the resident, dated May 23, 2024, revealed that the resident needed dialysis and staff was to check for bruit and thrill (a bruit is a sound, and a thrill is a vibration that indicate good blood flow in a dialysis fistula or graft) each shift. Physician's orders for Resident 73, dated December 26, 2024, included an order for staff to monitor the resident's right upper chest med port (an access port placed in individuals receiving hemodialysis to ensure quality treatment and reduce the risk of infection) access area. Review of Resident 73's clinical record revealed that the resident did not have a dialysis access that would require staff to check for a bruit and thrill. Interview with Licensed Practical Nurse 2 on January 8, 2025, at 11:20 a.m. confirmed that Resident 73 only had a med port and no other dialysis access site that would require them to check for a bruit and thrill. However, there was no documented evidence that Resident 73's care plan was updated/revised to reflect individualized, specific care and services interventions to reflect that staff does not need to check a bruit and thrill. Interview with the Director of Nursing on January 8, 2025, at 12:56 p.m. confirmed that Resident 73's care plan was not updated/revised to reflect individualized, specific care and services interventions to reflect that staff does not need to check a bruit and thrill. An admission MDS assessment for Resident 77, dated November 25, 2024, revealed that the resident was cognitively impaired, was sometimes understood and able to sometimes understand others, and required assistance with care needs. A care plan for Resident 77, dated December 3, 2024, indicated that the resident was to ambulate with the assist of two and use of a front-wheeled walker and was to transfer with assist of two and use of a front-wheeled walker or utilize grab bar where available. Physician's orders for Resident 77, dated November 21, 2024, included an order for the resident to ambulate with one assist and use of a front- wheeled walker. Physician's orders for Resident 77, dated November 21, 2024, included an order for the resident to transfer with one assist and use of a front-wheeled walker or utilize grab bar where available. Interview with the Director of Nursing on January 9, 2025, at 10:39 a.m. confirmed that there was no documented evidence that Resident 77's care plan was revised to reflect her current transfer status. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 31 residents reviewed (Residents 27, 50, 77), and failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 69). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 2, 2024, revealed that the resident was understood and could understand others, and had a diagnosis which included hypertension (high blood pressure). A care plan for the resident, dated August 8, 2024, revealed that the resident had an altered cardiovascular (relating to the heart and blood vessels) status related to hypertension and that staff were to administer the resident's medications per orders. Physician's orders for Resident 27, dated April 22, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Hydralazine (used to treat high blood pressure) three times a day. Staff was to hold the medication if the resident's systolic blood pressure (the top number of a blood pressure) was less than 100 millimeters of mercury (mmHg) or if the resident's heart rate was less than 60 beats per minute. Review of Resident 27's clinical record, including the resident's Medication Administration Record (MARs), dated November and December 2024, and January 2025, revealed no documented evidence that staff was obtaining the resident's blood pressure and heart rate prior to the administration of the one 10 mg tablet of Hydralazine three times a day. Interview with the Director of Nursing on January 8, 2025, at 10:43 a.m. confirmed that there was no documented evidence that staff was obtaining Resident 27's blood pressure and heart rate prior to the administration of the one 10 mg tablet of Hydralazine three times a day. An admission MDS assessment for Resident 50, dated December 9, 2024, revealed that the resident had mild cognitive impairment, was understood and able to understand others, had pain, was administered routine and as needed pain medications, required substantial assist with bed mobility, was dependent for transfers, was not ambulatory, was frequently incontinent of bowel, had two Stage 2 pressure ulcers (pressure wound with skin loss) present on admission, had a surgical wound and wound infection, had a pressure-relieving device to bed and chair, and received pressure ulcer care and surgical wound care. A care plan for Resident 50, dated December 3, 2024, revealed that the resident had actual skin impairment and that staff was to administer treatments as directed. Physician's orders for Resident 50, dated January 3, 2025, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL (a narcotic drug used to treat moderate to severe pain) every four hours as needed for moderate to severe pain. Review of Resident 50's MAR for January 2025 revealed that 10 mg of Oxycodone HCL was administered to the resident on January 4, 2025, at 12:11 a.m. and 1:11 p.m.; January 5, 2025, at 2:52 p.m., 6:56 p.m. and 11:15 p.m.; and January 6, 2025, at 5:09 a.m. However, a review of the resident's controlled medication record (a form that accounts for each tablet/pill/dose of a controlled drug), dated January 2025, revealed that 10 mg of Oxycodone HCL was not signed out for administration on the above-mentioned dates and times. Interview with the Director of Nursing on January 9, 2025, at 2:07 p.m. confirmed that 10 mg of Oxycodone HCL was not signed out on Resident 50's controlled medication record as being administered on the above-mentioned dates and times. Physician's orders for Resident 50, dated December 3, 2024, included an order to apply betadine (a solution used to treat and prevent infection) to the intergluteal cleft and buttocks flap closure with sutures and cover with comfort foam twice daily. A review of the resident's Treatment Administration Record (TAR), dated December 2024, revealed that the resident did not receive the treatment as ordered on December 4, 8, 10 and 21, 2024, on the day shift. Interview with the Nursing Home Administrator on January 9, 2025, at 10:39 a.m. confirmed that there was no documented evidence that the treatment to Resident 50's interguteal cleft and buttocks flap closer was administered to the resident on the above-mentioned dates and shifts. An admission MDS assessment for Resident 77, dated November 25, 2024, revealed that the resident was cognitively impaired, was sometimes understood and able to sometimes understand others, required assistance with care needs, and had a diagnosis of hypertension (high blood pressure). A physician's order for Resident 77, dated November 27, 2024, included an order for the resident to receive 25 mg of Lopressor (a medication used to treat hypertension) twice daily with instructions to hold the medication if the resident's heart rate was less than 60 beats per minute. Review of the Resident 77's MAR for November and December 2024, as well as review of the resident's clinical record, revealed no documented evidence that the resident's heart rate was obtained prior to administering the Lopressor. Interview with the Director of Nursing on January 8, 2025, at 1:35 p.m. confirmed that there was no documented evidence that Resident 77's heart rate was obtained prior to administering the Lopressor. A quarterly MDS assessment for Resident 69, dated November 20 , 2024, revealed that the resident was cognitively intact and was always incontinent of bowel movements. Physician's orders for Resident 69, dated September 16, 2024, included orders for the resident to receive 30 milliliters (mL) of Milk of Magnesia (MOM) as needed for constipation if no bowel movement by day three, a 10 mg bisacodyl suppository rectally as needed if no bowel movement for three days after MOM, and Fleets enema to be given rectally as needed if no bowel movement for four days. The resident's care plan, dated October 31, 2024, indicated that the resident had constipation and mediations were to be administered as directed. Review of Resident 69's bowel records for November and December 2024 revealed that there was no documented evidence that the resident had a bowel movement from November 2 through 8 and December 26 through 30, 2024. Review of the November and December 2024 MAR's for Resident 69 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. Interview with the Director of Nursing on January 9, 2025, at 11:31 a.m. confirmed that the physician's orders for bowel medications were not followed for Resident 69. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on resident and staff interviews, and a meal test tray, it was determined that the facility failed to serve food items that were palatable to the residents. Findings include: Interview with Resident 73 on January 7, 2025, at 10:47 a.m. revealed that when she receives her meal tray, the food is not as warm as she likes it to be, and the taste of the food has a lot to be desired. Interview with Resident 74 on January 7, 2025, at 10:33 a.m. revealed that the food is cold. Interview with Resident 77 on January 7, 2025, at 11:12 a.m. revealed that the food is terrible and she only drinks milk. Interview with a group of residents on January 8, 2025, at 10:07 a.m. revealed that food is an ongoing issue. The food is cold, food is dry, and they always have pork and chicken. Interview with Resident 45 on January 8, 2025, at 12:07 p.m., while she was eating sweet and sour pork for lunch, revealed that she could not taste the sweet and sour. Observations in the kitchen of the tray line for the East Side Third floor cart on January 8, 2025, at 11:38 a.m. and First cart for East Side Third floor was completed at 11:40 a.m. A separate, open, non-insulated cart was used for overflow trays for the rest of East side. Staff indicated that there was not enough room to put all of the trays on the insulated, enclosed cart. Juices and milk were kept on top of the enclosed cart in a bin of ice. The meal for lunch included scalloped chicken with mushrooms, alternate of sweet and sour pork, buttered potatoes, mixed vegetable blend, and chocolate pudding. The last tray was placed on the open cart and left the kitchen at 11:45 a.m., arrived on East Side Third floor at 11:46 a.m The first tray was out at 11:47 a.m. and at 11:51 a.m. last tray was removed from the cart. The test tray was removed from the open cart at 11:51 a.m. The food items were not palatable to taste or temperature. Both the chicken and the pork were tested . The scalloped chicken with mushrooms was 140 degrees Fahrenheit (F). The texture was soft, but the taste was bland. The mushroom gravy on top of the chicken had no taste and there were no visible mushrooms. The alternate of sweet and sour pork was 122 degrees F, the texture was soft and shredded, but was cool and the taste was bland. There were no visible pineapple chunks and no taste of sweet and sour. Interview with the food service director and the Dietician at the time of the test tray indicated that because of cardiac diets, they do not put salt in the food, and the residents are given salt packets on their trays. Interview with [NAME] 8 and the Food Service Director on January 8, 2025, at 3:18 p.m. indicated that they follow the recipes. The Food Service Director indicated that the green peppers and onions in the pork recipe cook down a bit when cooking them. There were no visible green peppers or onions noted to the pork when tasting it. Also, she indicated that they use only pineapple juice when preparing the pork and do not use the pineapple chucks called for in the recipe. The recipe for the pork also called for brown sugar, vinegar and soy sauce. When informed that the pork had no taste that resemble these flavors, the cook indicated that she probably could add more brown sugar. The chicken recipe called for breadcrumbs and parmesan cheese. There were no visible breadcrumbs noted on observation of the chicken or when tasting the chicken. There was no taste of parmesan cheese to the chicken. Both the Food Service Director and the cook indicated that they do not use salt to flavor due to cardiac diets and salt if offered and placed on the trays. 28 Pa. Code 211.6(b) Dietary Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food preparation, dated August 28, 2024, revealed that the dinning services director/cook is responsible to ensure that proper practice is utilized in thawing frozen foods. One method is that frozen foods are completely submerged under cold water (70 degrees or below) that is running fast enough to agitate and float off loose ice particles. Observations in the kitchen on January 7, 2025, at 8:49 a.m. revealed a large bag of chicken in a sealed plastic bag in the kitchen sink submerged in water. No running water was observed. Observations in the kitchen on January 7, 2025, at 9:06 a.m. revealed a large bag of chicken in a sealed plastic bag in the kitchen sink submerged in water. No running water was observed. Interview with the Food Service Director at that time indicated that they usually put the frozen chicken in the cooler to thaw, but it was needed to prep for a meal today, so the cook placed it in cold water to thaw. She indicated that this was the process. Interview with the Food Service Director on January 8, 2025, at 12:10 p.m. indicated that the sink fills up and the water is shut so it does not overflow and is turned back on. She indicated that the temperature of the water was below 70 degrees. She indicated that she was not sure if the cook took the temperature of the water or not, but she would check. At that time, she was not able to confirm if the chicken had been thawed with running cold water as per the policy. Observations of the nourishment station on the Third-floor South side on January 8, 2025, at 9:13 a.m. revealed a cooler with some ice in it and the ice scoop was lying in the ice. Interview with Nurse Aide 10 on January 8, 2025, at 9:25 a.m. confirmed that the ice scoop should not have been lying inside the cooler in the ice. She indicated that some coolers have a fixed container on the coolers to place the scoop in. That cooler did not have that. There was a plastic container with a scoop in it observed under the cart the cooler was on. She does not know why there were two scoops in there. She indicated that they get the ice from the ice machine in the nourishment station on the East side of the Third floor. Interview with the Director of Nursing on January 8, 2025, at 10:45 a.m. confirmed that the ice scoop should not have been in the cooler in the ice. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain dignity for one of 33 residents reviewed (Resident 34) who had an indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated December 19, 2024, indicated that the resident was understood and able to understand others, and had an indwelling urinary catheter (a flexible tube used to drain urine from the bladder into a drainage collection bag). A care plan for the resident, dated April 29, 2024, revealed that the resident had an indwelling urinary catheter. Staff were to cover the urinary drainage bag with a dignity cover and position the catheter bag and tubing below the level of the bladder and away from entrance room door. Physician's orders for Resident 34, dated August 22, 2024, included an order for the resident to have an indwelling urinary catheter for a diagnosis of obstructive uropathy (a condition that occurs when urine is blocked from draining through the urinary tract). Observations of Resident 34 on January 7, 2025, at 10:41 a.m. and 11:33 a.m. revealed that the resident was lying in bed with his indwelling urinary catheter drainage bag hooked to the bedframe on the door side of the bed. The bag was not covered and yellow urine was visible. Interview with Licensed Practical Nurse 1 on January 7, 2025, at 11:34 a.m. confirmed that Resident 34 did not have a dignity (privacy) cover on his indwelling urinary catheter bag and that it was positioned on the door side of the bed. Interview with the Director of Nursing on January 7, 2025, at 2:40 p.m. confirmed that Resident 34's indwelling urinary catheter drainage should have been covered with a dignity (privacy) cover. 28 Pa. Code 201.29(c) Resident Rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to develop an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for two of 31 residents reviewed (Residents 10, 46). Findings include: The facility policy regarding advance directives, dated August 28, 2024, indicated that prior to or upon admission of the resident, the social services director or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written advance directive. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or resident representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident and/or resident representative is given the option to accept or decline assistance. The nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated December 19, 2024, indicated that the resident was cognitively impaired, was usually understood and usually able to understand others, had severely impaired vision, and was dependent with care needs. An annual MDS assessment for Resident 46, dated October 17, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, and required assistance for care needs. Review of Residents 10's and 46's medical records indicated that they did not have advance directives. There was no documented evidence in the residents' clinical records that the residents and/or resident representatives were given the opportunity to develop an advance directive and no documented evidence of the residents' and/or resident representatives' decisions to accept or decline assistance in formulating advanced directives. Interview with the Nursing Home Administrator on January 9, 2025, at 10:39 a.m. confirmed that there was no documented evidence in Resident 10's or Resident 46's clinical records that the residents and/or resident representatives were given the opportunity to develop an advance directive and no documented evidence of the residents' and/or resident representatives' decisions to accept or decline assistance in formulating advanced directives. 28 Pa. Code 201.29(a)(d) Resident Rights.

Based on observations and staff interviews, it was determined that the facility failed to provide a homelike environment for three of 31 residents reviewed (Residents 19, 69, 84). Findings include: Observations of Resident 19 on January 8, 2025, at 8:50 a.m. revealed that the resident was sitting in her room in a facility recliner that had the leather covering on the arms, seat and back of the chair heavily shredded and torn. In order to provide comfort, the resident had her own blanket covering the back of the chair. When asked if she minded the torn upholstery, the resident indicated that she would rather it had a brown slipcover like her roommate's recliner. Observations of Resident 69 on January 7, 2025, at 10:22 a.m. and January 8, 2025, at 8:57 a.m. revealed that the resident was sitting in his room in a facility recliner that had the leather covering on the arms, seat and back that was very heavily shredded and torn. Observations of Resident 84's facility recliner on January 8, 2025, at 8:53 revealed that the arms and back of the leather-type covering was shredded and torn. Interview with the Maintenance Supervisor on January 8, 2025, at 9:10 a.m. confirmed that Resident 19's, 69's and 84's recliners should have had slipcovers on them. Interview with the Nursing Home Administrator on January 8, 2025, at 9:16 a.m. confirmed that Resident 19, 69 and 84 are currently using recliner chairs that have the leather covering torn and in some cases heavily shredded. He went on to say that most of the recliners have brown slipcovers on them, but it has been difficult finding more slipcovers to purchase that fit the recliners. The Nursing Home Administrator indicated that the torn/shredded recliners are not homelike and should not be used by the residents. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for two of 31 residents reviewed (Residents 61, 73). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated December 6, 2024, indicated that the resident was cognitively intact, was understood, and could understand others. A nursing note, dated November 29, 2024, at 1:18 p.m., revealed that Resident 61 was diaphoretic (sweating), slurring words, and hypoxic. The resident began to vomit brown liquid and was then sent to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 61's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS assessment for Resident 73, dated November 21, 2024, revealed that the resident was understood, and could understand others. A nursing note for Resident 73, dated December 22, 2024, at 7:03 a.m., revealed that the writer was notified by the licensed practical nurse that the resident's blood pressure was low at 60/40 millimeter of mercury (mmHg) (a normal blood pressure is less than 120/80 mmHg). The resident was pale, diaphoretic (excessive sweating due to a secondary condition), clammy, with her eyes closed, and she would respond to physical stimuli only. The physician was notified and a new order was received to send the resident to the hospital at this time. A nursing note at 2:26 p.m. revealed that the resident was admitted to the hospital. There was no documented evidence that a written notice of Resident 73's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. Interview with the Director of Nursing on January 8, 2025, at 2:18 p.m. confirmed that there was no documented evidence that a written notice of Resident 61's and 73's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of four residents reviewed (Residents 1, 2), resulting in Immediate Jeopardy to the resident's physical/mental health and safety. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated March 22, 2023, revealed that the facility shall provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors or family members. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 29, 2023, revealed that the resident was sometimes understood, could sometimes understand, required extensive assistance with her daily care tasks including with eating, was totally dependent on staff for her transfers, and had diagnoses that included dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). An incident note for Resident 1, dated October 28, 2023, at 2:30 p.m. revealed that Nurse Aide 3 notified the Registered Nurse Supervisor about witnessing physical abuse to Resident 1 during lunch at 12:30 p.m. However; Nurse Aide 3 did not report the abuse to her supervisor at that time. Resident 1 was sleeping in the Atrium at dinner and it was witnessed that Nurse Aide 2 slapped the resident on the left cheek and told her to wake the f**k up multiple times. The resident was unable to be aroused enough to answer any questions. The Registered Nurse Supervisor immediately assessed Resident 1 and no injuries were noted to the resident. Nurse Aide 2 was escorted out of the facility. Staff was re-educated on abuse and reporting, and no staff were allowed to work without receiving the re-education. All of the residents were interviewed, and skin assessments were performed. The physician and the resident's power of attorney (POA - a person who is legally authorized to make decisions for a person who can no longer make them) were notified. A quarterly MDS assessment for Resident 2, dated September 8, 2023, revealed that the resident was confused, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included Alzheimer's disease and dementia. A nursing note for Resident 2, dated October 28, 2023, revealed that the nurse aide reported an allegation of abuse by another staff member to the Registered Nurse Supervisor. The resident was calling the nurse aide a whore and the nurse aide slapped him in the face, hitting his nose. She continued providing care to him and he told her to touch his [NAME] and she replied, No, you're a dirty black man, you're a faggot that touches little boys. She smacked him on the top of his head. The nurse aide who was assisting told her she should not do that, and Nurse Aide 2 said she did not give a f**k. An Investigative Interview statement from Nurse Aide 5, dated October 28, 2023, revealed that at around 1:15 p.m. she and Nurse Aide 2 went into Resident 2's room to change the resident. The resident called Nurse Aide 2 a whore and she smacked him in the mouth. Nurse Aide 5 told Nurse Aide 2 that she should not do that and she said, Where I'm from I smack residents around. When they were putting a new brief on the resident he asked her if she wanted to touch his [NAME]. She smacked him on the nose and told the resident that he was a dirty black man who loves little boys and was a faggot. They pulled him up in bed and he said she was in the KKK and she smacked him on top of his head. They covered him up and left the room. An Investigative Interview statement from Nurse Aide 1, dated October 28, 2023, revealed that at 12:30 p.m. during lunch in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on the left cheek and say, wake the f**k up. She did this several times. An Investigative Interview statement from Nurse Aide 3, dated October 28, 2023, revealed that at 12:30 p.m. in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on her left cheek multiple times and told her to wake the f**k up. An Investigative Interview statement from Registered Nurse 4, dated October 28, 2023, at 3:27 p.m. revealed that Nurse Aide 5 told Registered Nurse 4 that she needed to talk to her in private. As they entered the nursing station on 3 East, she led her to the bathroom then told her that Nurse Aide 2 hit Resident 2 and called him names while they were changing him. She told Nurse Aide 2 she should not do that, and Nurse Aide 2 stated, I'll do what I want. Nurse Aide 5 said that Nurse Aide 2 had also hit Resident 1 earlier and told her to wake the f**k up, and that Nurse Aide 3 saw it. An Investigative Interview statement from Licensed Practical Nurse 7, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 5 reported to her that she witnessed another nurse aide smacking a resident in the mouth, on the nose, and called him a dirty black man who loves little boys and was a faggot. The resident said she was in the KKK so she smacked him on the head. Nurse Aide 5 indicated that she wrote a report and turned it in to Registered Nurse 4 Following the incident with Resident 2 on October 28, 2023, the facility's corrective actions included: Nurse Aide 2 was escorted out of the facility, and after the investigation her employment with the facility was terminated. An audit of current residents was started. Re-education regarding abuse to staff, and staff were not allowed to work until re-education had been completed. Ongoing random audits of residents were being completed. The audits were to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. On November 7, 2023, at 5:30 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Residents 1 and 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Residents 1 and 2 were not subjected to physical/mental abuse by Nurse Aide 2, who physically/mentally abused the residents. On November 8, 2023, at 11:01 a.m. the facility submitted an immediate action plan that included: The nurse aide was suspended at the time of the reported abuse, and is no longer employed at the facility. An in-house audit was performed on all residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified. In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work. Ongoing random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at QAPI. Facility staff were interviewed on November 8, 2023 and were knowledgeable of the facility's policy on abuse. The facility alleged compliance on November 2, 2023. The Immediate Jeopardy was lifted on November 8, 2023, at 11:25 a.m. when it was confirmed that the corrective action plans developed on October 28, 2023, were completed by November 2, 2023, and that Residents 1 and 2 and any other current residents were not physically/mentally abused since November 2, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 2) and staff failed to report physical abuse of one resident (Resident 1) in a timely manner which allowed a second resident to be physically abused (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical safety. Findings include: The facility's abuse policy, dated March 22, 2023, revealed that the facility shall provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors, or family members. All allegations of abuse should be reported immediately to the charge nurse, Director of Nursing, Nursing Home Administrator, and the resident's physician for investigation into the circumstances of the incident. The staff member who discovers the incident, suspected abuse situation, or has the initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The supervisor who becomes aware of such incidents must immediately report to the Nursing Home Administrator and the Director of Nursing in person or by telephone. An incident note for Resident 1, dated October 28, 2023, at 2:30 p.m. revealed that Nurse Aide 3 notified the Registered Nurse Supervisor about witnessing physical abuse to Resident 1 at 12:30 p.m. during lunch. The resident was sleeping in the Atrium at dinner and it was witnessed that Nurse Aide 2 slapped the resident on the left cheek and told her to wake the f**k up multiple times. The resident was unable to be aroused enough to answer any questions. The Registered Nurse Supervisor immediately assessed the resident and then escorted Nurse Aide 2 out of the facility. No injuries were noted to the resident. There was no documented evidence that the physical abuse of Resident 1 by Nurse Aide 2 was reported to the Registered Nurse Supervisor immediately when it happened. A nursing note for Resident 2, dated October 28, 2023, revealed that a nurse aide reported an allegation of abuse by another staff member to the Registered Nurse Supervisor. At approximately 1:15 p.m. Resident 2 was calling Nurse Aide 2 a whore and Nurse Aide 2 slapped him in the face, hitting his nose. She continued providing care to him and he told her to touch his [NAME] and she replied, No, you're a dirty black man, you're a faggot that touches little boys. She smacked him on top of his head. The nurse aide who was assisting told her she should not do that and Nurse Aide 2 said she did not give a f**k. An Investigative Interview statement from Licensed Practical Nurse 7, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 5 reported to her that she witnessed Nurse Aide 2's physical abuse of Resident 2. Nurse Aide 5 indicated that she had not reported the incident yet; then wrote a report and turned it into the Registered Nurse 4. An Investigative Interview statement from Licensed Practical Nurse 6, dated October 28, 2023, revealed that at 1:30 p.m. Nurse Aide 7 reported to her that she witnessed Nurse Aide 2's physical abuse of Resident 2. Nurse Aide 7 indicated that she had not reported the incident yet; then wrote a report, and turned it into the Registered Nurse 4. An Investigative Interview statement from Registered Nurse 4, dated October 28, 2023, at 3:27 p.m. revealed that Nurse Aide 5 told Registered Nurse 4 that she needed to talk to her in private. As they entered the nursing station on 3 East, she led her to the bathroom then told her that Nurse Aide 2 hit Resident 2 and called him names while they were changing him. She told Nurse Aide 2 that she should not do that, and Nurse Aide 2 stated, I'll do what I want. The nurse aide said Nurse Aide 2 also hit Resident 1 and told her to wake the f**k up and that Nurse Aide 3 saw it. An Investigative Interview statement from Nurse Aide 3, dated October 28, 2023, revealed that at 12:30 p.m. in the Atrium she witnessed Nurse Aide 2 smack Resident 1 on her left cheek multiple times and told her to wake the f**k up. An Investigative Interview statement from Nurse Aide 5, dated October 28, 2023, revealed that at around 1:15 p.m. she and Nurse Aide 2 went into Resident 2's room to change the resident. The resident called Nurse Aide 2 a whore and she smacked him in the mouth. Nurse Aide 5 told Nurse Aide 2 that she should not do that and she said, I'm from another facility and I smack residents around. When they were putting a new brief on the resident he asked her if she wanted to touch his [NAME], she then smacked him on the nose, and told the resident that he was a dirty black man who loves little boys and was a faggot. They pulled him up in bed and he said she was in the KKK and she smacked him on top of his head. They covered him up and left the room. Interview with the Nursing Home Administrator on November 7, 2023, at 1:50 p.m. confirmed that Nurse Aide 5 failed to report the abuse timely, so she was suspended, then given re-education regarding the reporting of abuse, then given a final written warning, and placed on a 90-day probation. Nurse Aide 3 was terminated because she did not report the witnessed abuse to Resident 1 until they were interviewing her about the abuse toward Resident 2. Following the incident with Resident 2 on October 28, 2023, the facility's corrective actions included: Nurse Aide 2 was escorted out of the facility, and after the investigation her employment with the facility was terminated. An audit of current residents was started. Re-education regarding abuse and reporting abuse to staff, and staff were not allowed to work until re-education had been completed. Ongoing random audits of residents were being completed. The audits were to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. The facility's abuse policy, dated March 22, 2023, revealed that nurse aides who are currently on the registry will have their registry checked for past incidences of abuse, neglect, mistreatment of residents, and misappropriation of resident property prior to hiring for employment. The prevention of resident abuse and neglect is accomplished by the completion of pre-employment screening of potential employee registries, completion of a criminal record check of all employees, and per-employment reference checks of potential hires. The personnel file for Nurse Aide 5 revealed that she was hired July 7, 2023. She was provided education on abuse, neglect, and exploitation on July 8, 2023. She successfully completed her nurse aide training program on June 22, 2023, and received her Pennsylvania Nurse Aide Registry on September 18, 2023. The personnel file for Nurse Aide 2 revealed that she was hired on March 29, 2023. However, there was no documented evidence until November 7, 2023, at 8:41 a.m. that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified. She was provided education on abuse, neglect, and exploitation on April 12, 2023. Nurse Aide 2's time record, dated October 28, 2023, revealed that she punched in for duty at 12:06 p.m. and punched out at 2:25 p.m. Interview with the Nursing Home Administrator on November 7, 2023, at 2:23 p.m. confirmed that the Nurse Aide Registry check for Nurse Aide 2 was not completed as required. On November 7, 2023, at 5:30 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Resident 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Nurse Aide 5 immediately reported the witnessed abuse to Resident 1 by Nurse Aide 2 to their supervisor as per the facility's policy. On November 8, 2023, at 11:01 a.m. the facility submitted and implemented an immediate action plan that included: The reporting of abuse was not immediate. Notification of the abuse was made in two hours. Re-education was given to staff on the importance of reporting abuse immediately along with the facility abuse policy/procedure. Employees were not permitted to work before receiving re-education. Upon notification, the nurse aide (perpetrator) was escorted out of the facility immediately. The perpetrator was terminated following the conclusion of the investigation. The facility conducted audits of the residents for signs of abuse. No additional residents were identified from the audit. Ongoing random audits of residents are being completed weekly. The audits are going to be reviewed at QAPI. The facility acknowledged compliance on November 2, 2023. Nurse Aide Registry verifications were obtained on the nurse aide identified as not having the registry verifications completed prior to hire. Certifications are current and active. In-house audit of employee files have been completed on November 7, 2023. All employees with licenses or certifications have been validated as being current and active. Re-education will be given to the Human Resources Director on ensuring that pre-employment verifications and checks are completed before employees start. The Nursing Home Administrator or designee will be auditing new employee charts as new employees are hired to ensure that the process is completed prior to them starting on the floor. Employees not having all the required pre-employment items and supporting documentation will not be permitted to work until all items are received. Review of those audits will be taken to QAPI for continuation or resolution of audit. The facility acknowledged compliance on November 8, 2023. The Immediate Jeopardy was lifted on November 8, 2023, at 11:25 a.m. when it was confirmed that the corrective action plans developed on October 28, 2023, and November 8, 2023, were implemented. It was confirmed that Residents 1 and 2 and any other current residents were not physically/mentally abused. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented. All employees with licenses or certifications have been validated as being current and active. Re-education had been given to the Human Resources Director on ensuring that pre-employment verifications and checks are completed before employees start. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that supervision and adequate interventions were in place to prevent a resident from receiving food items from other residents outside of their ordered diet restrictions for one of six residents reviewed (Resident 2), and failed to ensure that supervision and adequate interventions were in place to prevent a resident from giving other residents food items outside of their ordered diet restrictions for one of six residents reviewed (Resident 1). The facility's failure created a situation in which Resident 2 obtained a food item outside of his ordered diet restriction causing him to accidentally choke to death. The facility's failure also placed the current residents with diet restrictions in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death. The facility also failed to ensure that supervision and adequate interventions were in place to prevent a resident from assisting other residents in their wheelchairs without leg rests for one of six residents reviewed (Resident 1). Findings include: The facility's behavior policy, dated [DATE], indicated that should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the nurse supervisor/charge nurse must immediately implement the policy and procedure for unmanageable residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], indicated that the resident was moderately cognitively impaired, was independent with transfers and ambulation (walking), had no behaviors, and had diagnoses that included dementia, anxiety, and depression. A quarterly MDS assessment for Resident 2, dated [DATE], revealed that the resident was sometimes understood, sometimes understands with a Brief Interview for Mental Status (BIMS) score of 09, indicating that the resident was moderately impaired with his attention, orientation, and ability to register and recall new information; required supervision of one-person physical assist with eating; required extensive assistance from staff with his daily care tasks; was totally dependent on staff for his transfers; and had a diagnosis of dementia. The resident experienced holding of food in his mouth/cheeks or residual food in his mouth after meals and experienced coughing or choking during meals or when swallowing medications during the review period. The resident was on a mechanically-altered diet that required a change in the texture of food or liquids. A significant change in status MDS assessment for Resident 2, dated [DATE], revealed that the resident was usually understood, could usually understand, had severe cognitive impairment, was independent with eating after set-up, required extensive assistance from staff for his daily care tasks, was totally dependent on staff for his transfers, had a diagnosis of dementia and was on a mechanically-altered diet that required a change in the texture of food or liquids. A care plan for Resident 2, dated [DATE], revealed that the resident was at risk for aspiration (when something you swallow goes down the wrong way and enters your airway or lungs) complications related to coughing and impulsiveness at mealtimes. Staff was to ensure that the resident's diet and liquid consistency was followed as ordered. A nursing note for Resident 2, dated [DATE], at 5:41 p.m. revealed that the resident experienced a coughing episode during the dinner meal on a mechanical soft diet. The resident was eating too fast and not chewing his food well. The resident was also not drinking his honey thick fluids and was coughing after consuming the fluids. The resident was assessed by the registered nurse. A nursing note at 5:44 p.m. revealed that the physician was made aware that the resident was eating dinner very fast and aspirated on his food. A new order for a chest x-ray to rule out aspiration was received. A speech language pathologist (SLP) evaluation for Resident 2, dated [DATE], revealed that the resident was referred because the resident had a coughing event on [DATE], and now presents with wheezing. SLP services warranted to determine safest diet level. Physician's orders for Resident 2, dated [DATE], and discontinued on [DATE], included an order for the resident to receive a Carbohydrate Controlled Diet (CCD) pureed (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding) texture, with honey (slightly thicker, similar to honey or a milkshake) consistency liquids, and no regular creamer. An incident note for Resident 2, dated [DATE], at 6:58 p.m. revealed that the resident was given iced tea by his roommate. The roommate thought he was dry and thought he would give him a drink. The resident coughed on the drink. Education was provided to the roommate that he is not to give other resident's drinks due to special ordered diets and liquid consistency. A SLP discharge summary for Resident 2, dated [DATE], revealed that the resident has a good prognosis to maintain his current level of function with consistent staff follow through and her discharge recommendations were for a pureed consistency diet with honey thick liquids, to encourage slow intake with small bites in an upright position along with encouraging consumption. Staff was to provide verbal cues to decrease rate and size as needed along with distant supervision. A nursing note for Resident 2, dated [DATE], at 8:54 a.m. revealed that he was yelling out to another resident in hallway to come to his room. The resident then motioned to that resident that he was hungry by drawing his hand up to his mouth. As the writer approached the residents, the other resident gave Resident 2 an oatmeal cream pie. The resident consumed some of the oatmeal cream pie, until she was able to educate him and the other resident that his diet is pureed and honey thick and it is not okay to have anything other than pureed food and honey thick liquids unless therapy okays it in the future. The resident became mad and yelled, I hate you! and I'm mad!. The resident then stormed back into his room in his wheelchair. A nursing note for Resident 1, dated [DATE], at 9:07 a.m. revealed that the resident was educated by the Director of Nursing that he could not be offering other residents food because he was not aware of their diets. Resident 1 was noted to be giving a resident, who was ordered a pureed diet, mechanical soft food in the hallway. Resident 1 stated that he was sorry, and he did not want to get anyone in trouble or hurt anyone. Education was effective. A nursing note for Resident 2, dated [DATE], at 9:26 a.m. revealed that the resident is at baseline for behaviors at this time. The resident does not like his diet and will eat items not on his diet if given the opportunity. The resident does not take redirection or education well. A nursing note for Resident 2, dated [DATE], at 10:06 a.m. revealed that the nurse aide notified the writer that another male resident was seen coming out of the resident's room. Upon approaching the resident, he wiped small crumbs of peanut butter crackers off his shirt. The writer tried to educate resident again and he just shook his head and laughed. The education was not successful. Physician's orders for Resident 2, dated [DATE], and discontinued on [DATE], included an order for the resident to receive a CCD pureed texture diet, with honey consistency liquids, no regular creamer, extra sauce and gravy, and food in bowls. A nursing note for Resident 2, dated [DATE], at 9:13 p.m. revealed that staff reported to the writer that the resident was eating a cheese cracker and drinking thin consistency soda in his room. Upon entering the resident's room, the resident was no longer eating or drinking. Surroundings were assessed and there were cracker crumbs on his wheelchair and on the floor next to him. When asked if he was eating the crackers and drinking the soda he replied with a nod of his head. It was explained to him the risks of not following the appropriately prescribed diet including choking, aspiration, respiratory infection, and even death. The resident's response was to shrug his shoulders. The physican was made aware of the resident not following his prescribed diet, and no new orders were received. The resident's representative was updated and gave permission for the resident's room to be searched periodically for food and drink items. A nursing note for Resident 1, dated [DATE], at 12:56 p.m. revealed that Licensed Practical Nurse 1 was walking in the hallway when she turned the corner and saw Resident 1 hand Resident 2 a hard candy, which Resident 2 ate. Resident 1 was educated that per Resident 2's diet, it was not safe for him to have hard candy, as he could choke. Resident 1 was asked if he heard her to ensure that the education was understood and he stated, It melts, it's fine, he won't choke. She told him that it was not safe for Resident 2 and he was to refrain from sharing food that was not pureed due to safety. At 1:17 p.m. Resident 1 told Licensed Practical Nurse 1 the only way Resident 2 was going to learn how to eat was if he was taught. She told Resident 1 that was not how it worked and if that was part of his care plan, they would take care of it. Resident 1 stated that she was not the boss of him, and he would do what he wanted and stated, You know nothing, I know what I'm doing. Licensed Practical Nurse 1 told him that if something would happen to Resident 2, once he knowingly gave him food that was unsafe for him, that he could be responsible, and that it was all about safety. The situation was reported to the Director of Nursing. A nursing note for Resident 2, dated [DATE], at 12:59 p.m. revealed that the nurse was walking in the hallway when she turned the corner and happened to see Resident 1 hand the resident a hard candy, which the resident then proceeded to swallow once he saw the nurse. The nurse then educated the resident that he cannot have hard candy with his diet. The nurse also let Resident 1 know that it is not safe for resident to have hard candy. Neither of the residents seemed receptive to the education. Physician's orders for Resident 2, dated [DATE], and discontinued [DATE], included an order for the resident to receive a CCD mechanical soft (designed for people who have trouble chewing and swallowing. Chopped, ground and pureed foods are included in this diet, as well as foods that break apart without a knife) texture diet, with thin liquids, extra sauce and gravy, may have regular creamer, and food in bowls. Physician's orders for Resident 2, dated [DATE], included an order for the resident to receive a CCD mechanical soft texture diet, with honey consistency liquids, extra sauce and gravy, and food in bowls. A nursing note for Resident 2, dated [DATE], at 2:04 p.m. revealed that the writer was notified by a nurse aide at 1:00 p.m. that the resident was not breathing. Upon entering the resident's room, the resident was found with his head hanging forward toward his chest. The resident did not respond to verbal stimuli. The resident's head was lifted, the carotid pulse (pulse in the neck) was checked and was absent. There was no breathing noted. The resident had cracker crumbs on his chest. The nurse aides used a mechanical lift to return resident to bed while the licensed practical nurse and the writer confirmed the resident's code status from his chart. The resident was confirmed to be a Do Not Resuscitate (DNR). Upon return to the resident's room and due to a lack of a pulse and absence of breath, he was pronounced at 1:05 p.m. The Nursing Home Administrator and Assistant Director of Nursing were notified of the resident's change in status. The Death Certificate for Resident 2, dated [DATE], revealed that accidental choking led to asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death). A witness statement completed by Registered Nurse 4, dated [DATE], revealed that Nurse Aide 5 came and got the nurse to look at Resident 2. She stated, don't think he is breathing. The nurse ran to his room. Resident 1 did not have a carotid pulse and was not breathing. The nurse noticed orange cracker crumbs on his chest. The licensed practical nurse and the nurse went to confirm his code status while the aides put him to bed in case they needed to start Cardiopulmonary Resuscitation (CPR). The aides stated that they cleaned his face. The nurse also noted cracker crumbs on the floor of his room. A witness statement completed by Nurse Aide 5, dated [DATE], revealed that at 1:00 p.m. her and Nurse Aide 6 started to lay people down after lunch. They started with Resident 2. As soon as she walked into the room, she noticed that the resident was not breathing. She ran over to the East Hall and got the registered nurse. They both ran to Resident 2's room. Nurse Aide 5 and Nurse Aide 6 laid him down with the lift. There were orange cracker crumbs all over his shirt, lift pad, and wheelchair. While cleaning him up he had crackers in his mouth and coming out his nose. A witness statement completed by Nurse Aide 6, undated, revealed that around 1:00 p.m. in the afternoon her and Nurse Aide 5 went into Resident 2's room to change him. His head was down. They lifted his head up and it fell back down. His eyes were open, and food was in his mouth and nose. Nurse Aide 5 went to get help and Nurse Aide 6 stayed in the room, wiped off his face, and tried a sternal rub. Food was all over his shirt. The charge nurse came in the room and said to go ahead and lay him down. When they got him in bed there were cracker crumbs all through the sling and on the dura pad that they had wiped off. Interview with Resident 1 by the Nursing Home Administrator, dated [DATE], revealed that he had asked the resident if he shared any of his snacks with any other residents and his reply was no. He then asked the resident where he got his snacks, and he said that his brother brought them in for him. Information provided by the facility revealed that the type of cracker in Resident 2's possession was not a brand or type of cracker ordered or supplied by the facility. Resident 2 had no other snacks in his room that were inconsistent with his current ordered diet. A full house audit was conducted to determine if any other residents had the same orange crackers in their possession. Resident 1, who lives a few doors down from Resident 2, had the same small packs of orange crackers. Upon review of Resident 1's record, he has been observed in the past sharing his snacks with other residents. Education was provided at that time on not offering or sharing food or snacks with other residents for their safety. Interview with Speech Language Pathologist on [DATE], at 12:40 p.m. revealed that she had worked with Resident 2 in the past and had recommended a diet downgrade to pureed diet with honey consistency liquids due to his impulsive eating. She indicated that the resident's sister wanted his diet upgraded due to not liking the pureed diet and experiencing weight loss, so his diet was upgraded to a mechanical soft diet. She indicated that she follows dietary's list of foods that are approved for a mechanical diet. She indicated that as a SLP standpoint she uses any food that can be cut easily with a fork, then she would consider that food to be a mechanical soft food. She indicated that she would not consider a peanut butter cracker a mechanical soft food item unless it was softened with a liquid. She indicated that the resident was very difficult to work with because he was such an impulsive eater. You could not get him to slow down when eating even with cueing and education. She indicated that he was not on her radar to see about advancing his diet because of his impulsive eating. She indicated that the resident would not be safe to eat peanut butter crackers or to be given peanut butter crackers from another resident. Interview with the Dietician on [DATE], at 1:04 p.m. revealed that that dry cheese crackers would not be considered a mechanical soft food unless it was softened with a liquid. A review of Resident 1's clinical record revealed that there was no documented evidence that new interventions were put into place to monitor and prevent Resident 1 from giving food to other residents that were on restricted diets. A nursing note, dated [DATE], at 12:32 p.m. revealed that Resident 1 was presented with education regarding resident diet/snacks and he verbalized understanding of the education that was given. It was stressed the adverse effects that could occur with giving residents food outside of their prescribed diet. Resident 1 stated, I have always been a giver and I like to share things, but I guess I can't. It was explained that it was a kind gesture, but it could cause harm to other residents and snacks should not be shared. He was agreeable and stated that he would not share snacks with other residents. A nursing note, dated [DATE], at 5:28 p.m. revealed that Resident 1 was seen getting off the elevator by the East nurse's station with multiple bags of snacks and candy. He was re-educated on not sharing snacks with any other resident. He was not receptive to the education and yelled, Don't tell me that! I don't do that! Interview with the Nursing Home Administrator on [DATE], at 2:45 p.m. revealed that there was no documented evidence that any interventions, other than education, were put into place to prevent Resident 1 from giving food to other residents. Interview with Nurse Aide 5 on [DATE], at 2:45 p.m. revealed that she had previously seen cracker crumbs on the Resident 1's floor and in his wheelchair before. As of [DATE], there was no documented evidence that the facility developed and/or implemented any new interventions and/or supervision to prevent Resident 2 from obtaining food items outside of his ordered diet. Following the incident on [DATE], the facility's corrective actions included: On [DATE], a whole house audit for snacks in resident rooms was completed. If snacks were found, education was provided to the resident and/or the resident's responsible party. They were asked if the snack that was not in line with the resident's current diet order could be removed. If the resident and/or the resident's responsible party was in agreement with the removal of the snack, the snack was then removed from the resident's room. On [DATE], a current in-house resident audit of diet order/tray ticket information/care plan was completed. On [DATE], a call was placed to the residents' family/representative regarding the facility's meal and snack safety protocol. [DATE], education to staff regarding meal and snack safety was started. On [DATE], a resident council meeting was held to discuss snack and food protocol. On [DATE], daily audits started for snacks in rooms/sharing was started. On [DATE], at 3:15 p.m. the Executive [NAME] President of Operations and the Nursing Home Administrator were informed that the health and safety of Resident 2 and the health and safety of current residents were in Immediate Jeopardy due to the failure to ensure that supervision and adequate interventions were in place to prevent Resident 1 and/or other identified residents from giving other residents food items outside of their ordered diet restrictions. The facility submitted and implemented an immediate action plan that included placing Resident 1 in a private room, install a motion detector alarm on Resident 1's door to alert staff that he is outside of his private room, and the resident will be provided one-on-one supervision while outside his room or when other residents enter his room. The education included ensuring that staff administer appropriate snacks and to also monitor any residents that were sharing snacks with other residents that are against their diet order and notify nursing immediately so appropriate intervention and action can be taken, families and resident representatives were educated on ensuring they are providing the appropriate snacks that are consistent with the residents' current physician-ordered diet, future admissions will be provided education on the facility's meal and snack safety protocol upon admission to the facility. Audits will be completed by the Director of Nursing and/or designee to ensure that staff are following the process. Audit information would be reviewed and discussed during QA meetings for recommendations or resolution to improve the process. The Immediate Jeopardy was lifted on [DATE], at 3:35 p.m. when it was confirmed that the facility had placed Resident 1 in a private room with a motion detector and secured his snacks in a location outside of his room. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented. A nursing note, dated [DATE], at 8:54 a.m. revealed that Licensed Practical Nurse 2 was called to talk to Resident 1 about why he should not push other residents in the hallways. Resident 1 stated that he liked helping out because it kept him healthy. He was educated that pushing other residents was not allowed for him for their safety. A nursing note, dated [DATE], at 5:57 p.m. revealed that Resident 1 entered the dining room during the evening meal and proceeded to push another resident back to the resident's room. Resident 1's education to not push other residents was ineffective. A nursing note, dated [DATE], at 9:17 a.m. revealed Resident 1 was trying to escort a female resident to her room. He was educated that he was not allowed to push other residents around the facility because it was a safety issue. The resident in the wheelchair was capable of using her wheelchair to get back and forth to the dining room without assistance. Resident 1 was being defiant and his behaviors actually increased since being educated. A nursing note, dated [DATE], at 4:48 p.m. revealed that Resident 1 was educated that he was not to be pushing other residents to the dining room due to safety for him and the resident, and he acknowledged the education. A nursing note, dated [DATE], at 1:01 p.m. revealed that Resident 1 had not learned form previous education that pushing other residents may potentially cause harm to him or the other resident. Resident 1 was found pushing another male resident from the dining room towards his room. The resident was removed from Resident 1's possession and he was educated that it was not his responsibility to push other residents and that if residents needed assistance from staff, staff needed to provide the assistance for safety reasons. A nursing note, dated [DATE], at 9:15 a.m. revealed that the Director of Nursing witnessed Resident 1 pushing Resident 4 in her wheelchair without leg rests. Staff immediately intervened and provided education to Resident 1. He was not receptive to the education, although he did stop pushing the wheelchair. As she continued down the hallway and around the corner she witnessed Resident 1 again pushing Resident 4 without leg rests. She attempted to intervene again but was ignored by Resident 1, at which time the physical therapist stepped in and intervened. However, as of [DATE], there was no documented evidence that the facility developed and/or implemented any new interventions and/or supervision to prevent Resident 1 from assisting other residents in their wheelchairs without leg rests. Interview with Licensed Practical Nurse 3 on [DATE], at 1:51 p.m. revealed that she had seen Resident 1 push other residents before while they were in their wheelchairs and he was told to stop at that time. Interview with the Director of Nursing on [DATE], at 1:37 p.m. confirmed that she observed Resident 1 push Resident 4 in her wheelchair without leg rests and then push her again after he was educated not to. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, investigative reports and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow the facility's policy, for one of 32 residents reviewed (Resident 53), resulting in a fall with a head injury. Findings include: The facility's policy regarding the use of wheelchairs, dated (MONTH) 9, (YEAR), indicated that foot rests (a supportive surface on a wheelchair for the feet to rest on) were to be used when transporting residents in a wheelchair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated (MONTH) 11, (YEAR), revealed that the resident had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 9, (YEAR), revealed that she was at risk for falls and had an unsteady gait, and poor judgement and safety awareness. Investigative documents for Resident 53, dated (MONTH) 31, (YEAR), revealed that at approximately 5:10 p.m. Nurse Aide 3 transported the resident to the dining room in her wheelchair. The resident suddenly put her foot down onto the floor and fell face first onto the floor. Upon assessment by Registered Nurse 2, Resident 53 had a small hematoma to her mid-forehead measuring 5.0 x 4.5 centimeter (cm) and a laceration to her mid-forehead measuring approximately 2.5 cm. When questioned if she had any pain, the resident stated that her head hurt. The physician was notified and the resident was sent to the emergency room . Information submitted by the facility, dated (MONTH) 1, (YEAR), revealed that while at the hospital, the resident received seven staples to the laceration on her forehead. A nursing note regarding the incident for Resident 53, dated (MONTH) 31, (YEAR), at approximately 5:10 p.m. revealed that staff notified the registered nurse that the resident was on the floor and the nurse visualized the resident lying on her right side on the floor with Nurse Aide 3 kneeling at her head. Resident 53's wheelchair was pushed away from her and was sitting by the entrance to the atrium. It was noted that there were no foot rests in place. The facility's investigation determined that Nurse Aide 3 violated the facility's policy when she transported Resident 53 in a wheelchair without using foot rests. Interview with the Nursing Home Administrator on (MONTH) 12, (YEAR), at 2:06 p.m. confirmed that Nurse Aide 3 did not use foot rests on Resident 53's wheelchair. The Nursing Home Administrator indicated that the facility educated all staff on (MONTH) 5, (YEAR), regarding the importance of using foot rests on wheelchairs while transporting residents from place to place to maintain safety. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/28/16. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/18/17, 4/28/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/18/17, 12/29/16, 4/28/16.

Based on review of policies, investigative reports and clinical records, as well as staff interviews, it was determined that the facility failed to take precautions to prevent injury to a resident caused by not having foot rests on her wheelchair during transport, for one of 32 residents reviewed (Resident 53), resulting in a fall with a head injury. Findings include: The facility's policy regarding the use of wheelchairs, dated (MONTH) 9, (YEAR), indicated that foot rests (a supportive surface on a wheelchair for the feet to rest on) were to be used when transporting residents in a wheelchair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated (MONTH) 11, (YEAR), revealed that the resident had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 9, (YEAR), revealed that she was at risk for falls and had an unsteady gait, and poor judgement and safety awareness. Investigative documents for Resident 53, dated (MONTH) 31, (YEAR), revealed that at approximately 5:10 p.m. Nurse Aide 3 transported the resident to the dining room in her wheelchair. The resident suddenly put her foot down onto the floor and fell face first onto the floor. Upon assessment by Registered Nurse 2, Resident 53 had a small hematoma to her mid-forehead measuring 5.0 x 4.5 centimeter (cm) and a laceration to her mid-forehead measuring approximately 2.5 cm. When questioned if she had any pain, the resident stated that her head hurt. The physician was notified and the resident was sent to the emergency room . Information submitted by the facility, dated (MONTH) 1, (YEAR), revealed that while at the hospital, the resident received seven staples to the laceration on her forehead. A nursing note regarding the incident for Resident 53, dated (MONTH) 31, (YEAR), at approximately 5:10 p.m. revealed that staff notified the registered nurse that the resident was on the floor and the nurse visualized the resident lying on her right side on the floor with Nurse Aide 3 kneeling at her head. Resident 53's wheelchair was pushed away from her and was sitting by the entrance to the atrium. It was noted that there were no foot rests in place. The facility's investigation determined that Nurse Aide 3 violated the facility's policy when she transported Resident 53 in a wheelchair without using foot rests. Interview with the Nursing Home Administrator on (MONTH) 12, (YEAR), at 2:06 p.m. confirmed that Nurse Aide 3 did not use foot rests on Resident 53's wheelchair. The Nursing Home Administrator indicated that the facility educated all staff on (MONTH) 5, (YEAR), regarding the importance of using foot rests on wheelchairs while transporting residents from place to place to maintain safety. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/18/17, 4/28/16. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/18/17, 12/29/16, 4/28/16.