Every finding on record at Pleasant Ridge Manor East/West

Based on review of clinical records, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, it was determined that the facility failed to ensure that a quarterly Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), was completed within the required time frame for one of 37 residents reviewed (Resident R46). Findings include: The Long-Term Care Facility RAI 3.0 User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that the assessment reference date (ARD- the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 calendar days after the ARD of the most recent assessment of any type. Resident R46's clinical record revealed an admission date of 2/12/24, with diagnoses that included Dementia (loss of cognitive functioning affecting a person's memory and behaviors), Transient Ischemic Attack ( TIA - occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and Peripheral Vascular Disease (A common condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping). Resident R46's clinical record revealed an annual MDS Assessment with an ARD of 1/15/26. The next MDS assessment completed had an ARD of 5/21/26, 34 days past the required 92 calendar days. During an interview on 6/4/26, at 10:40 a.m. Registered Nurse Assessment Coordinator confirmed that Resident R46's quarterly MDS ARD was past the required 92-days from his/her last MDS ARD. 28 Pa. Code 211.5(f) (ix) Medical records

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interviews it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 36 residents reviewed (Residents R5 and R213).Findings include: Resident R5's clinical record revealed an admission date of 4/10/17, with diagnoses that included Malignant Neoplasm of Pancreatic Duct (Cancerous tumor that originates in the cells lining the ducts of the pancreas [a large gland behind the stomach which secretes digestive enzymes into the intestines]), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R5's physician's orders dated 11/24/25, revealed an order that the resident was admitted under Hospice Services with admitting diagnosis of Malignant Neoplasm of the Pancreatic Duct. Resident R5's quarterly MDS with an Assessment Reference date (ARD) of 4/30/26, MDS Section O Special Treatments, Procedures, and Programs O0110 K1 Hospice Care was coded as No. During an interview on 6/4/26, at 11:58 a.m. Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R5's 4/30/26 quarterly MDS was coded incorrectly and should have been coded Yes that he/she was receiving hospice services. Resident R213's clinical record revealed an admission date of 11/21/25, with diagnoses that included difficulty swallowing, kidney disease, dementia, and adult failure to thrive [syndrome of progressive physical, cognitive, and functional decline, often marked by weight loss, poor nutrition, decreased appetite, and inactivity]. Resident R213's physician's orders dated 12/3/25, revealed an order to admit to Hospice services. Resident R213's quarterly MDS's with an ARD of 2/19/26, and 5/14/26, MDS Section O Special Treatments, Procedures, and Programs O0110 K1 Hospice Care was coded as No. During an interview on 6/4/26, at 12:50 p.m. the Nursing Home Administrator confirmed that Resident R213's 2/19/26, and 5/14/26, quarterly MDS's were coded incorrectly and should have been coded Yes that he/she was receiving hospice services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of 36 residents reviewed (Resident R121). Findings include: Review of facility policy dated January 2026, entitled Administering Medications revealed The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones; As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site; any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. Resident R121's clinical record revealed an admission date of 12/1/25, with diagnoses that included Osteomyelitis of the vertebra, sacral and sacrococcygeal region(infection of the bone including the back and pelvis), Chronic Kidney Disease ( a long-term condition in which the kidneys are damaged and gradually lose their ability to function properly over time), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Review of Resident R121's May 2026 IV (Intravenous) Administration Record revealed the following orders: Physician's order dated 5/4/26, for Central Line (an IV inserted in a vein near the heart): Document total volume infused per shift every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 58 were documented as completed and 24 were blank. Physician's order dated 5/4/26, for Central Line: Flush all unused ports( a device used to deliver IV medications) with 10cc (cubic centimeter) NSS (normal saline solution) in 10cc syringe every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 58 were documented as completed and 24 were blank. Physician's order dated 5/4/26, for Central Line: Flush port with 10cc NSS in 10cc syringe before and after medication administration every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 57 were documented as completed and 25 were blank. Physician's orders with numerous start and stop dates for the month of May 2026, for Vancomycin HCL Intravenous Solution (an antibiotic administered by IV) for Osteomyelitis. Out of 51 total opportunities to document completion, 34 were documented as completed and 17 were blank. During an interview on 6/4/26, at 12:10 p.m. the Director of Nursing confirmed that Resident R121's clinical records were incomplete regarding IV documentation. 28 Pa. Code 211.5(f)(ii)(viii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and maintain oxygen equipment according to physician's orders for three of five residents reviewed for respiratory services (Residents R32, R153, and R195). Findings include: Review of facility policy entitled Oxygen Administration dated 6/18/25, revealed to verify that there is a physician's order for this procedure. Review the physician's order . for oxygen administration. and turn on oxygen. Unless otherwise ordered, start the flow of oxygen at . and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of facility policy entitled Oxygen Saturation Pulse Oximetry (SPO2) Oximetry protocol dated 6/18/25, revealed to verify/obtain a physician's order; unless otherwise determined and prescribed by the physician, utilize 90% SPO2 as acceptable; increase or decrease oxygen liter flow by one liter per minute or more. Review of facility policy entitled Cleaning Nebulizer Cone and Mask or Mouth Piece dated 6/18/25, revealed that the resident will be provided with new nebulizer supplies every seven days; and rinse nebulizer T-set ( T-shaped connection between the mouthpiece or mask to the nebulizer chamber to facilitate delivery of aerosolized medication) nightly with wamr water and leave to dry on a clean paper towel. Review of facility policy entitled Medication Orders dated 6/18/25, revealed that oxygen orders must specify the rate of flow, route, and rationale. Resident R32's clinical record revealed an initial admission date of 7/28/22, with diagnoses that included Alzheimer's disease (progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out even simple tasks), functional quadriplegia (complete inability to move due to severe disability or frailty, not caused by a spinal cord injury or brain damage), and adult failure to thrive (syndrome of decline in older adults characterized by weight loss, decreased appetite, poor nutrition, and inactivity). Resident R32's clinical record revealed a physician's order dated 5/20/25, for Ipratropium-Albuterol Solution (bronchodilators that relax muscles in the airways and increase air flow to the lungs) inhaled through a nebulizer mask four times a day. Review of Resident R32's Medication Administration Record (MAR) revealed that he/she routinely received the nebulized medications four times a day. There no evidence in the Treatment Administration Record (TAR) of cleaning/maintaining nebulizer equipment. Observations on 6/23/25, at 2:05 p.m., 6/24/25, at 11:46 a.m., and 6/25/25, at 11:06 a.m., revealed a nebulizer mask laying directly on Resident R32's nightstand and that the inside portion of the mask contained dried secretions, and an unidentifiable solid matter. During an interview on 6/26/25, at 1:10 p.m. Registered Nurse Employee E2 confirmed that the nebulizer mask was soiled, and there was no evidence of when the mask was changed or cleaned. Review of Resident R153's clinical record revealed an initial admission date of 1/06/23, with diagnoses that included prostate cancer, Type 2 diabetes (chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), altered mental status, and dementia. The clinical record lacked evidence of a physician's order to provide supplemental oxygen (O2). A departmental progress note dated 6/23/25, at 11:50 a.m. revealed that Resident R153 experienced a potential seizure, and that O2 was initiated at two liters per minute and his/her oxygen saturation was recorded at 99%. Review of Resident R153's MAR/TAR and departmental progress notes dated 6/23/25, to 6/25/25, lacked evidence of documentation of his/her continued use of O2, the liter flow, or route. Observations on 6/23/25, at 3:48 pm., and 6/24/25, at approximately 10:10 a.m. revealed that Resident R153 was observed in bed with O2 in use at two liters per minute. During an interview on 6/25/25, at 1:30 p.m. Registered Nurse Employee E2 and Licensed Practical Nurse Employee E3 confirmed Resident R153's clinical record contained incomplete orders and parameters for the use of O2, and lacked documentation of continued use of O2, route and liter flow. Review of Resident R195's clinical record revealed an admission date of 2/18/25, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), dementia (a disease that affects short term memory and the ability to think logically), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R195's physician's orders revealed an order for oxygen via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) for comfort only, do not titrate SATS (blood oxygen saturation levels) dated 2/21/25, and another order for oxygen per oximetry (a device that provides an oxygen level by placing it on a person's finger) PRN (as needed) dated 2/18/25. The oxygen orders lacked a flow rate (the amount of oxygen to be delivered). During an interview on 6/26/25, at 10:10 a.m. the Director of Nursing (DON) confirmed that Resident R19's oxygen orders lacked a flow rate. The DON also confirmed that Resident R19's oxygen orders were incomplete, and all oxygen orders should indicate a flow rate. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of 35 residents reviewed (Resident R19). Findings include: Review of facility policy entitled Transfer and Discharge Policy dated 6/18/25, indicated When the facility transfers or discharges a resident . the facility must ensure that the transfer or discharge is documented in the residents medical record and appropriate information is communicated to the receiving health care institution or provider. And Documentation of the resident's medical record must include: . Information provided to the receiving provider . Review of Resident R19's clinical record revealed an admission date of 12/12/24, with diagnoses that included respiratory failure (a condition where your lungs don't exchange air properly), congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R19's clinical record revealed a progress note dated 5/15/25, at 3:50 p.m. indicating the resident was transfered to the hospital. The clinical record lacked evidence that Resident R19's necessary clinical information was communicated to the receiving health care provider. During an interview on 6/25/25, at 2:35 p.m. the Director of Nursing (DON) confirmed that there was no evidence that the necessary clinical information for Resident R19 was provided to the receiving healthcare provider upon transfer. The DON also confirmed when a resident is transferred the necessary clinical information should be provided to the receiving health care provider and documented in the resident's clinical record. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of 35 residents reviewed (Resident R197). Findings include: Review of Resident R197's clinical record revealed an admission date of 12/11/24, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident R197's clinical record revealed a physician's order dated 1/30/25, to apply edema glove (a compression glove to reduce swelling) to left hand. Review of tasks (area in the clinical record where nursing assistants document) revealed a task to apply Geri sleeve (special sleeve worn to protect the skin from injury) to left upper extremity on in the a.m. and off at hour of sleep (HS). Observations on 6/23/25, at 3:22 p.m. revealed Resident R197 sitting in his/her wheelchair in their room with no glove/sleeve on their left hand/arm. Observation on 6/24/25, at 9:18 a.m. revealed Resident R197 was lying in their bed with no glove/sleeve on their left hand/arm. Observation again on 6/24/25, at 12:40 p.m. revealed the resident was sitting in their wheelchair with no glove/sleeve on their left hand/arm. Observations on 6/25/25 at 9:00 a.m., 1:30 p.m., and again at 1:40 p.m. revealed the resident sitting in their wheelchair with no glove/sleeve on their left hand/arm. During an interview on 6/25/25, at 1:40 p.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that Resident R197 did not have a glove/sleeve on his/her left hand/arm. LPN Employee E5 also confirmed that Resident R197 should have a glove/sleeve to their hand/arm according to physician's orders. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical record, observations, and staff interview, it was determined that the facility failed to ensure that resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of four residents reviewed (Resident R120). Findings include: Review of policy entitled Restorative Nursing: Splints and Orthotics dated 6/18/25, indicated upon receipt of a physician's order the occupational/physical therapist will issue a splinting device for the resident and nursing staff will follow recommendations/physician's orders and instructions. Review of Resident R120's clinical record revealed an admission date of 3/2/21, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), contracture of muscle (a condition that affects a muscle to fully stretch or relax causing the muscle to become stiff and unable to bend), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R120's clinical record revealed a physician's order dated 10/22/24, for bilateral resting hand splints per standard wear schedule off at breakfast, on at 1:00 p.m., off at supper, on at hour of sleep, off at 2:00 a.m., on at 4:00 a.m. Review of Resident R120's tasks (an area in the clinical record where the nursing assistants document) revealed that documentation lacked evidence that the bilateral resting hand splints were applied per physician's orders. Observations on 6/24/25, at 1:40 p.m. revealed Resident R120 was sitting in his/her wheelchair with no resting hand splints on their bilateral hands. Observation on 6/25/25, at 1:00 p.m. and again at 1:45 p.m. revealed Resident R120 lying in his/her bed with no resting hand splints on their bilateral hands. During an interview on 6/25/25, at 1:45 p.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that Resident R120 did not have resting hand splints on his/her bilateral hands. LPN Employee E5 also confirmed that Resident R120 should have his/her resting hand splints on their bilateral hands per physician's orders. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that medications subject to abuse were stored in separately locked, permanently affixed compartment in one of three medication refrigerators (H Unit), and failed to ensure that medications were discarded in a timely manner for one of three medication rooms observed (A Unit). Findings include: A facility policy entitled Storage of Medications on Nursing Unit dated 6/18/25, revealed that controlled substances that require refrigeration will be secured in the red box designated for controlled substances and secured with a pull tight seal or lock. A facility policy entitled Return of Medication to the Pharmacy dated 6/18/25, revealed that all of the discontinued medication (except controlled substances) will be sent to the pharmacy for credit and/or disposal. Observation on 6/23/25, at 2:15 p.m. of the H Unit medication storage refrigerator revealed Ativan (anti-anxiety, controlled medication) injection syringes, in the red plastic box designated for controlled medications and the box lacked a lock/device to secure the contents. During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E1 confirmed the controlled medication box was not secure. During an interview on 6/23/25, at 2:29 p.m. the Director of Nursing (DON) confirmed the red controlled medication box should have a lock/secure device. Observation on 6/23/25, at 3:05 p.m. of the A Unit medication storage refrigerator revealed 1 ½ - 100 milliliter (mL) multi-dose bottles of Cefpodoxime (antibiotic) and one 100 mL bag of Meropenem (antibiotic) intravenous (IV) solution labeled as filled on 6/16/25, and with instructions to discard after 6/21/25. During an interview at that time, LPN Employee E6 confirmed that the bottles and IV bag of antibiotics were expired and should have been discarded/returned to pharmacy. During an interview on 6/23/25, at 3:56 p.m. the DON confirmed that the expired medications should have been discarded or returned to the pharmacy. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 201.18(b)(1) Management

Based on review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), clinical records and staff interview, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for two of 35 residents reviewed (Residents R13 and R43). Findings include: Resident R13's clinical record revealed an admission date of 1/9/25, with diagnoses that included bipolar disorder (condition of mood swings characterized by manic highs and depressive lows), anxiety, and chronic pain. Review of MDS instructions for section K0300 indicated that if weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months to code yes. During an interview on 6/26/25, at 8:55 a.m. the Registered Dietitian confirmed that R13 did not have significant weight loss and the MDS dated [DATE], for section Swallowing/Nutritional Status Section K0300 Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months was coded incorrectly. Resident R43's clinical record revealed an initial admission date of 6/07/24, with diagnoses that included Type 2 diabetes (chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), long-term kidney disease, and adult failuer to thrive (syndrome of decline in older adults characterized by weight loss, decreased appetite, poor nutrition, and inactivity). Resident R43's clinical record revealed a physician's order originally dated 6/08/24, and reordered 5/28/25, to administer ticagrelor oral tablet (anti-platelet-prevents platelets in your blood from sticking together to prevent blood clots) three times a day. Review of MDS instructions for Section N0415 indicated to check if the resident is taking any of the listed medications by pharmacologial classification. Resident R43's Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Annual MDS dated [DATE], and Quarterly MDS dated [DATE], Sections N0415 indicated that Resident R43 was receiving an anticoagulant. During an interview on 6/25/25, at 2:56 p.m. Registered Nurse Assessment Coordinator Employee E4 confirmed that Resident R43's Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Annual MDS dated [DATE], and Quarterly MDS dated [DATE], Sections N0415 were coded incorrectly for receiving an anticoagulant. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, clinical records, and facility documents, and staff interviews, it was determined that the facility failed to ensure all alleged violations involving abuse were reported in a timely manner for one of six residents reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse - Reasonable Suspicion of a Crime - Prevention / Reporting dated January 2024, revealed the facility will not tolerate any form of abuse, exploitation, mistreatment or neglect of its residents, nor will it tolerate misappropriation of residents' funds or property by anyone. All covered individuals shall report any incident or suspicion of abuse, neglect, mistreatment, or misappropriation of funds or property immediately to the Abuse Coordinator (Director of Human Resources), Director of Nursing, or the Administrator / Executive Director, or in their absence to the RN Supervisor, or Charge Nurse. The policy further states for Protection, Identification, and Reporting that The Administrator / Executive Director, the Director of Nursing, and the Abuse Coordinator, must be informed as soon as possible of alleged abuse, neglect, mistreatment, or misappropriation of resident funds or property. The policy Process revealed that when an employee has reasonable cause to suspect that a resident is a victim of abuse, neglect, exploitation or abandonment, the employee shall report it to their supervisor, who will immediately report it to the facilities Executive Director, Director of Nursing, or Abuse Coordinator, and that staff will complete a Star Witness Report indicating the time, location, resident, and details of the allegation and submit it to the supervisor prior to the completion of his/her shift. Facility policy defines Physical Abuse as including, but not being limited to hitting, slapping, kicking, biting, spitting, or throwing items, etc. Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Resident R1's clinical record revealed an admission date of 4/21/16, with diagnoses that included dementia (loss of cognitive functioning affecting a person's memory and behaviors), tracheostomy(a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R1's quarterly Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) with an Assessment Reference Date (ARD) of May 22, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairments. Review of information submitted by the facility dated 5/22/25, identified that there was an incident during the end of the third shift the morning of 5/21/25, between 6:00 a.m. and 7:00 a.m. during a transfer using a mechanical lift with Resident R1, where NA Employee E6 pulled the resident's fingers off the lift and bent them backwards. NA Employee E6 was also observed to punch and pinch the resident while in the lift and in the wheelchair. NA Employee E4 told NA Employee E6 to stop, and he/she replied, You will shut up, you didn't see anything. NA Employee E4 went to report the incident and did not see their nurse before leaving their shift to report the event and therefore did not report the incident immediately before leaving the facility. The occurrence of the incident was not discovered until 5/22/25, at 7:40 a.m. when the Director of Nursing received a call regarding an allegation of resident abuse. The facility immediately initiated an investigation. During an interview on 6/10/25, at 2:00 p.m. with the Nursing Home Administrator (NHA), Director of Nursing (DON) and the Assistant Director of Nursing (ADON), they acknowledged that there was a delay in reporting the aforementioned allegation of abuse as the incident occurred on 5/21/25, at 6:15 a.m. and the DON was not notified until 5/22/25, at 7:40 a.m. The NHA, DON, and ADON also confirmed that staff are to report suspected allegations of abuse immediately. 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 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received an acute fracture of the femur (the thigh bone) for one of 35 residents reviewed (Resident R304). This deficiency is cited as past non-compliance. Findings include: The facility policy entitled, Lifting Machine, Using a Mechanical, dated January 26, 2024, indicated that at least two nursing assistants are needed to safely move a resident with a Full/Maxi mechanical lift and to follow transfer orders from Physical Therapy (PT) for sit to stand/Sara lift transfer orders. Review of Resident R304's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (progressive mental deterioration that destroys memory and other important mental functions), dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), history of falling and protein calorie malnutrition. Review of Resident R304's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs), dated 10/31/23, revealed that Resident R304's transfer status was total dependance, two-person physical assist, it also revealed that Resident R304 was severely cognitively impaired. Review of a physician's order dated 3/26/21, revealed that Resident R304 was ordered an assist x (times) 2 and with Maxi lift [full body mechanical lift] as needed with assist x 2 with transfers. A review of Resident R304's clinical record revealed a nurse's note dated 1/26/24, at 9:57 p.m. which indicated that Resident R304 had swelling to the right knee and bruising to the upper thigh and knee. A nurse's note dated 1/26/24, at 11:59 p.m. revealed that Resident R304 had large bruises noted to area behind the right knee and distal femur. Nursing Assistant (NA) Employee E13 stated that he/she used the Sara lift (sit to stand lift) to put resident to bed. The nurse's note also indicated that Resident R304's physician's order was a two-person assist or maxi lift. Orders received for x-rays in a.m. of the right hip, femur and knee. A nurse's note dated 1/27/24, at 11:36 a.m. revealed the physician was notified regarding the x-ray results of a displaced fracture of the right distal femur and indicated that Resident R304 was sent to the hospital for evaluation. Review of the facility's investigation revealed that NA Employee E12 confirmed verbally to Registered Nurse (RN) Employee E13 on a written statement dated 1/27/24, that he/she transferred Resident R304 with a Sara lift (sit to stand lift) to bed with assistance of one. A review of documentation submitted by the facility dated 1/27/24, revealed that the facility initiated an investigation, regarding Resident R304's injury of unknown origin on 1/26/24. The investigation revealed that the resident was transferred that day with an assist of one on 1/26/24. Following the transfer, the resident's leg had increased swelling and bruising. NA Employee E12 did not follow the resident's physician's orders for safe transfers resulting in harm and employment was terminated. An interview with the Director of Nursing (DON) on 7/29/24, at 10:40 a.m. confirmed that NA Employee E12 transferred Resident R304 with a Sara lift alone even though resident was ordered a Maxi lift as needed with an assist of two. The facility failed to ensure that Resident R304 was free from injury during a transfer resulting in actual harm of an acute fracture of the right femur. This deficiency is cited as past non-compliance. On 1/28/2024, the facility-initiated education for all nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and NAs to ensure that proper transfer status must be followed. This plan included the following: Immediate suspension of NA Employee E12 followed by termination of employment. Immediate education regarding following the resident's transfer orders and proper transfer technique was provided to all facility nursing staff that included RNs, LPNs, and NAs, which occurred from 1/27/2024, to 2/5/2024. Interviews with RN Employee E13 and LPN Employees E2, E3, E4, E6, E8 and E9 and NA Employees E1, E5, E7, E10, E14 and E15 confirmed the facility initiated education starting 1/27/2024, which included education on resident transfer status, following the resident's care plan, and with knowledge of where to find the resident's care plans, and all lifts require two staff. Audits were conducted by the DON regarding transfers to include the correct number of staff, and performed correctly, these audits of 25% of residents on each unit requiring a lift on every shift have been ongoing in the facility since February 2024. Per interview with the Nursing Home Administrator (NHA) and the DON, audits will continue to be completed by the RN Supervisors on each shift as well as the DON quarterly. These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee. The audits will continue until determined otherwise by the QAPI committee. During an interview with the NHA and DON on 7/30/24, at 11:40 a.m. and review of the facility's immediate actions, education, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm regarding proper transfers and had achieved substantial compliance as of 3/29/24. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for one of nine residents reviewed for bed-holds (Resident R65). Findings include: Review of facility policy entitled Bed Hold and Return Policy dated 1/26/24, indicated It is the policy . upon Admissions, Transfers and Therapeutic Leaves, residents and/or resident representatives will be informed in writing of the Bed Hold and Return Policy. Review of Resident R65's clinical record revealed an initial admitted [DATE], with diagnoses that included dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), diabetes (a health condition that caused by the body's inability to produce enough insulin), and obstructive and reflux uropathy (a condition that will not let the urine drain naturally). Review of Resident R65's clinical record revealed progress notes dated 10/3/23, at 4:13 a.m. and 2/2/24, at 10:40 p.m. indicating transfers to the hospital. The clinical record lacked evidence that Resident R65 and/or their representative were provided with a copy of the facility bed-hold policy upon transfers. During an interview on 7/30/24, at 2:41 p.m. the Director of Nursing confirmed that he/she had no evidence that Resident R65 and/or his/her representative was provided with a copy of the facility bed-hold policy that included the cost per day. He/she also confirmed that a copy of the facility bed-hold policy should have been provided to the resident and/or his/her representative upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for two of 35 residents reviewed (Residents R79 and R43). Findings include: Review of facility policy dated 1/26/24, entitled Restorative Nursing: Splints and Orthotics: Care of Resident With indicated that The Resident will receive care to assess for, prevent, and treat contracture and that Specific program is written onto the CNA (certified nurse aide) flow sheet and A copy of the splint / orthotic wearing schedule is placed in the resident's closet. Resident R79's admission record revealed an admitted [DATE], with diagnoses that included dementia (a condition that affects your ability to reason, think, or remember things), diabetes, and chronic obstructive pulmonary disease. Resident R79's clinical record revealed a physician's order dated, 8/9/21, that identified Palm splint to left hand. Non-standard wear schedule. The clinical record lacked a wear schedule for the palm splint and the resident's closet lacked evidence of a wear schedule being posted per facility policy. Observation on 7/28/24, at 1:25 p.m. revealed Resident R79 in bed with left hand splint laying on the night stand. Observation on 7/29/24, at 9:54 a.m. revealed Resident R79 in wheelchair with left hand splint laying on the night stand. Observation on 7/31/24, at 8:51 a.m. revealed Resident R79 in bed with left hand splint laying on the night stand. During an interview on 7/31/24, at 8:55 a.m. with Licensed Practical Nurse (LPN) Employee E11, surveyor inquired when Resident R79 was to be wearing his/her left palm splint. LPN Employee E11 reviewed physician orders and stated he/she did not see a wearing schedule for the splint, but believed it was to be put on at night as he/she knows it is not put on during the day shift. During an interview on 7/31/24, at 9:08 a.m. Nurse Aide (NA) Employee E16 was questioned on what shifts he/she worked, who responded that he/she works all three shifts. Surveyor asked NA Employee E16 how he/she knew when Resident R79 was to wear his/her splint. NA Employee E16 stated they just put the splint on when they can and when Resident R79 will let them. During an interview on 7/31/24, at 11:18 a.m. the Director of Nursing (DON) provided a copy of Resident R79's splint schedule that was implemented on 8/9/21. The splint schedule indicated the left palm splint was to be placed on after breakfast and removed for lunch, placed on after lunch and removed for supper, placed on after supper and removed at bedtime, placed on at midnight and removed at 2:00 a.m. DON confirmed the schedule was not posted in Resident R79's closet as policy indicated, that the splint should have been on Resident R79 at the times the surveyor observed the splint to be laying on the night stand and if the resident was refusing to allow staff to apply the splint, the refusal should have been documented in the clinical record. Resident R43's clinical record revealed an admitted [DATE], with diagnoses that included chronic respiratory failure (a condition were your lungs don't exchange air properly), intracranial injury (an injury to the brain caused by external force), and peripheral vascular disease (a condition where your arteries become narrow causing reduce or blocked blood flow). Review of Resident R43's clinical record revealed a physician's order dated 5/17/21, that identified an order for a left resting hand splint to be worn per standard wear schedule. Further review of clinical record revealed a care plan for Activities of Daily Living (ADL) for a left hand contracture. The ADL care plan also revealed interventions of splinting left hand program with standard wearing schedule. Review of therapy splint schedule and Restorative Nursing: Splints and Orthotics policy revealed resting hand splint should be on at 4:00 a.m. and taken off at 8:00 a.m., then on at 1:00 p.m. and taken off at 5:00 p.m., then on at 9:00 p.m. and taken off at 2:00 a.m. Observation on 7/28/24, at 1:00 p.m. revealed Resident R43 was sitting in his/her wheelchair in his/her room with no hand splint on his/her left hand. Observation on 7/28/24, at 3:47 p.m. revealed Resident R43 sitting in his/her wheelchair in the hall with no hand splint on his/her left hand. Observation on 7/29/24, at 2:17 p.m. revealed Resident R43 sitting in his/her wheelchair in his/her room with no hand splint on his/her left hand. Observation on 7/30/24, at 2:10 p.m. revealed Resident R43 sitting in his/her wheelchair in the hall with no hand splint on his/her left hand. Observation and interview with Licensed Practical Nurse (LPN) Employee E18 on 7/31/24, revealed that Resident R43's splint schedule was posted in Resident R43's closet. LPN Employee E18 opened Resident R43's closet door and revealed a paper taped to the inside of the door and indicated the standard wearing schedule for resting hand splint to left hand. Further interview with LPN Employee E18, revealed that he/she stated that Resident R43 did not wear the splint to his/her left hand during any part of LPN Employee E18's shifts on 7/28/24, and 7/29/24. During an interview with LPN Employee E18 on 7/31/24, at 8:57 a.m. he/she confirmed that Resident R43 did not wear his/her splint on his/her left hand as ordered and that the splint should have been on at the times of the observations. LPN Employee E18 also confirmed that the left resting hand splint should be placed to Resident R43's left hand as ordered. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of three residents reviewed for catheters (Resident R128). Findings include: A facility policy entitled Foley, Care Of dated 1/26/24, indicated Be sure the catheter tubing and drainage bag are kept off the floor and catheter bags should be covered with a catheter bag at all times. Review of Resident R128's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), chronic kidney disease, and retention of urine (a condition where the bladder doesn't empty completely when urinating). Review of Resident R128's clinical record revealed a physician's order dated 3/3/23, for an indwelling catheter related to urinary retention. Observations on 7/28/24, at 12:00 p.m. revealed that the bottom of Resident R128's urinary drainage bag was on the floor with the catheter cover only partially covering the urinary drainage bag. At 3:00 p.m. observations revealed that Resident R128's urinary drainage bag was laying flat on the floor, the tubing was lying on the floor, and the catheter cover was completely off the urinary drainage bag and wrapped up around the tubing. During an interview on 7/28/24, at approximately 3:05 p.m. Licensed Practical Nurse Employee E9 confirmed that Resident R128's catheter tubing and bag should not be on the floor, and the catheter cover should be completely covering the urinary drainage bag and not wrapped up around the tubing. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for two of seven residents reviewed for unnecessary medications (Residents R87 and R17). Findings include: A facility policy entitled Psychotropic Drugs dated 1/26/24, revealed that 1) All psychotropic's are required to have behavioral interventions and GDR's (gradual dose reductions). 2) PRN orders are limited to 14 days. Antianxiety/Hypnotic - If extended past 14 days, must include prescriber documentation of the rationale in the medical record and have a duration. Resident R87's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, hypertension (high blood pressure), and respiratory failure (difficulty breathing). A physician's order dated 11/22/23, identified to administer Alprazolam (anti-anxiety) 0.5 milligrams (mg) by mouth every 1 hour as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of the July 2024 Medication Administration Record (MAR) for Resident R87 revealed that the PRN Alprazolam was used on 7/1/24, 7/2/24, 7/3/24, 7/4/24, 7/5/24, 7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24, and 7/29/24. Review of the July 2024 MAR, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Alprazolam. During an interview on 7/30/24, at 2:10 p.m. the Director of Nursing confirmed that Resident R87's Alprazolam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and R87's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering Alprazolam. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a condition that affects your ability to reason, think, or remember things), arthritis, and transient ischemic attach (TIA - mini-stroke or where you develop stroke like symptoms that resolve within twenty-four hours). A physician's order dated 4/27/24, identified to administer Lorazepam (anti-anxiety) 0.5 mg / 0.25 milliliter (ml) sublingually (under the tongue) every 3 hours as needed for agitation, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Resident R17's April 2024 MAR revealed that the PRN Lorazepam was used eight times (4/27/24 twice, 4/28/24 three times, 4/29/24, and 4/20/24 twice). Review of the April 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam eight of eight times it was used. Resident R17's May 2024 MAR revealed that the PRN Lorazepam was used 16 times (5/2/24 three times, 5/4/24, 5/6/24, 5/7/24 twice, 5/8/24, 5/9/24 twice, 5/10/24, 5/11/24, 5/12/24, 5/17/24, 5/23/24, and 5/26/24). Review of the May 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam 12 of the 16 times it was used. Resident R17's June 2024 MAR revealed that the PRN Lorazepam was used five times (6/9/24, 6/17/24, 6/22/24, 6/24/24, and 6/26/24). Review of the June 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam five of the five times it was used. Resident R17's July 2024 MAR revealed that the PRN Lorazepam was used three times (7/1/24, 7/3/24, and 7/13/24). Review of the July 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam one of the three times it was used. During an interview on 7/31/24, at 9:53 a.m. the Director of Nursing confirmed that Resident R17's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and R17's clinical record lacked evidence that non-pharmacological interventions were attempted 26 of the 32 times PRN Lorazepam was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucometer meter (BGM - a device to collect and measure the level of glucose [sugar] in the blood) for two of 13 residents observed during the administration of medications (Residents R165 and R51). Findings include: Review of facility policy entitled Obtaining a Fingerstick Glucose Level dated 1/26/24, indicated to Clean and disinfect reusable reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of manufacturer's guidelines for cleaning and disinfecting procedures for the blood glucose monitoring system indicated that a variety of the most commonly used EPA (Environmental Protection Agency) registered wipes have been tested and approved for cleaning and disinfecting the blood glucose meter. The guidelines go on to indicate four different disinfectants that are approved for use - Clorox Germicidal Wipes, Dispatch Disinfectant Towel with Bleach, Super Sani-Cloth Germicidal Disposable Wipes, and CaviWipes. Observation of medication administration on 7/28/24, between 3:50 p.m. and 4:10 p.m. revealed that Licensed Practical Nurse (LPN) Employee E17 removed a blood BGM from the medication cart, wiped the meter with a 70% isopropyl alcohol prep pad, entered Resident R165's room, obtained a blood glucose level, returned to the medication cart, wiped the meter with a 70% isopropyl alcohol prep pad and placed the meter in the medication cart. LPN Employee E17 proceeded to the next resident, wiped the meter with a 70% isopropyl alcohol prep pad, entered Resident R51's room, obtained a blood glucose level, returned to the medication cart, wiped the meter with a 70% isopropyl alcohol prep pad and placed the meter in the medication cart. During an interview on 7/28/24, during medication observation, surveyor asked LPN Employee E17 if the 70% isopropyl alcohol prep pad was an approved cleaner for the BGM to which he/she replied they assumed it was and it is what he/she always uses. During an interview on 7/29/24, at approximately 2:00 p.m. the Director of Nursing confirmed that use of 70% isopropyl alcohol prep pad was not an approved cleaning agent for the BGM and the BGM should be cleaned after each use with a manufacturer's approved cleaning agent. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for seven of nine residents reviewed for baseline care plans (Residents R39, R59, R68, R183. R188, R22 and R65). Findings include: Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease that results in difficulty breathing, cough, and mucus production) diabetes, and Hodgkin lymphoma (cancer of the lymph nodes). R39's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R39 and/or his/her representative. Resident R59's clinical record revealed an admitted [DATE], with diagnoses that included dementia a condition that affects your ability to reason, think or remember things), COPD, and atrial fibrillation (irregular and often times a very fast heartbeat). R59's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R59 and/or his/her representative. Resident R68's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (difficulty swallowing), diabetes, and end stage renal disease (condition when your kidneys are no longer functioning properly). R68's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R68 and/or his/her representative. Resident R183's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, chronic kidney disease, and anxiety. R183's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R183 and/or his/her representative. Resident R188's clinical record revealed an admitted [DATE], with diagnoses that included hearing loss, chronic kidney disease, and age-related physical debility. R188's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R188 and/or his/her representative. Resident R22's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and diabetes. R22's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R22 and/or his/her representative. Resident R65's clinical record revealed an initial admitted [DATE], with diagnoses that included diabetes, and obstructive and reflux uropathy (a condition that will not let the urine drain naturally). R65's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R65 and/or his/her representative. During an interview on 7/30/24, at 2:04 p.m. the Director of Nursing confirmed that the clinical records of the residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies and clinical records, and staff interview, it was determined the facility failed to provide care in accordance with professional standards for care of a gastrostomy tube (G-tube-a surgically placed rubber tube placed into the stomach to deliver nutrition, water, and medications) for one of six residents reviewed. (Resident R1) Findings include: Review of facility policy entitled Administering medications via enteral feeding tube dated 1/2023, revealed, a slow gentle push with a piston syringe of water may only be done if medication will not flow in by gravity. Review of facility policy entitled Irrigation of feeding tubes dated 1/2023, revealed feeding tubes will be flushed with adequate amount of water to prevent formula residue from adhering to the tube causing a clogged tube. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (a condition that causes a person to not be able to swallow), diabetes (condition of improper blood sugar control), and Gastro Esophageal Reflux (acid reflux or heart burn). Review of Resident R1's clinical record revealed a nurse's progress note dated 2/20/24, that indicated Resident R1 was sent to the emergency room for evaluation due to a foreign object stuck in his/her G-tube. Review of a transfer form dated 2/20/24, indicated reason for transfer to emergency room was, G-tube clogged, and something stuck in it. Resident R1 was transferred to the emergency roiagnom on [DATE], at 9:00 p.m. Review of emergency department provider note dated 2/20/24, revealed on Resident R1's arrival to the emergency room his/her G-tube was removed and replaced with a new G-tube and a tip of a broken off Q-tip was felt in the G-tube that was removed. Review of Nurse Practitioner post emergency room documentation dated 2/22/24, indicated that Resident R1 was sent to hospital on 2/20/24, due to a foreign object that was inserted into Resident R1's G-tube which became lodged in the G-tube. During an interview on 3/05/24, at 2:50 p.m. the Director of Nursing confirmed that a foreign object should never be placed in a G-tube. He/she also confirmed that a foreign object should never be used to unclog a G-tube. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for three of 12 residents reviewed (Residents R1, R2, and R3). Findings include: Review of a facility policy entitled Resident Incident Reporting indicated that: all resident incidents are identified and tracked for compliance to assure follow-up on all resident incidents and provide treatment as appropriate; at the time of the incident staff will complete the Resident Incident Report including family/physician notification; all incidents are reviewed and care planned; and incidents are forwarded to the Director of Nursing (DON), Administrator (NHA), and Medical Director (MD) for review and comments if applicable. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included brain injury, epilepsy (brain disorder that causes recurring, unprovoked seizures), inability to speak, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). The clinical record also revealed a physician's order dated 9/18/23, at 11:50 p.m. to obtain an x-ray of the left pointer finger as soon as possible. Review of Resident R1's departmental progress notes revealed that on 9/19/23, at 8:17 a.m. staff Licensed Practical Nurse (LPN) documented discussed with second shift supervisor left pointer finger swollen, bruised, and possibly broken; at 11:00 a.m. x-ray to left pointer finger as soon as possible to rule out fracture, and may apply ice to finger; and at 2:11 p.m. an x-ray obtained at 11:30 a.m. Review of Resident R1's x-ray results dated 9/19/23, at 11:52 a.m. revealed no fracture nor dislocation of the left pointer finger. Further review of Resident R1's clinical record revealed lack of evidence that an investigation was initiated for an injury of unknown origin, or that the resident's representative was notified of the change in condition/injury and possible fracture. During an interview on 11/01/23, at 12:30 p.m. the Assistant Director of Nursing (ADON) and Administrator (NHA) confirmed that there was not evidence that an investigation was initiated or that Resident R1's family was notified of the injury and that there should have been an investigation initiated and notification to family. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease, obsessive-compulsive behavior (unreasonable thoughts and fears [obsessions] that lead to compulsive behaviors), difficulty walking, and restlessness/agitation. Review of an investigation dated 10/17/23, and provided by the facility on 11/01/23, indicated that staff discovered a bruise on Resident R2's right calf. There was no evidence that the physician and family were notified of the bruise. Review of Resident R2's departmental progress notes lacked follow-up assessments/treatments, and that notifications were made to the physician and family. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included epilepsy, dementia, wandering, and rhabdomyolysis (serious medical condition that can be fatal or result in permanent disability). Review of an incident investigation initiated 10/11/23, and provided by the facility on 11/01/23, lacked documentation of components of the investigation to include the type of incident, injury, assessment, treatment, follow-up actions, and notifications. Review of Resident R3's departmental progress notes lacked follow-up assessments/treatments, and that notifications were made to the physician and family. During an interview on 11/01/23, at 12:41 p.m. the ADON confirmed that Resident R3's clinical record lacked documentation related to lacked follow-up assessments/treatments, and notifications were made to the physician and family and additionally, during an interview on 11/01/23, at 1:02 p.m. the ADON confirmed there was no evidence that staff documented follow-up assessments and notified Resident R2's family of the bruise. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy and manufacturer's instructions, and staff interviews, it was determined that the facility failed to properly store a multi-use vial of medication with an opened date for one of three medication storage rooms reviewed and failed to safely secure/store medications for three of four medication storage rooms (Unit A, G, and J) reviewed. Findings include: Review of the facility policy entitled, Policy and Procedure for Medications, Storage of, dated of January 2023, identified that Medications will be securely stored according to state and federal regulations. No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the Pharmacy. Review of the manufacturer's instructions for storage of Lantus insulin vials revealed, The Lantus vials you are using should be thrown away after 28 days, even if it still has insulin left in it. Observation of medication storage room on Unit A, on 8/08/2023, at 2:39 p.m. revealed that a multi-use vial of Lantus insulin was in the refrigerator opened with no opened date and/or use-by date printed on the vial. During an interview with Licensed Practical Nurse (LPN) Employee E3 on 8/08/2023, at the time of the observation, it was confirmed that the multi-use vial of Lantus insulin was opened and in the refrigerator for use and there was no opened date and/or use-by date on the vial for staff to know if the medication was still safe for use or to discard. Review of the policy entitled, Storage of Medications, dated January 2023, revealed All medications for our residents are stored at the nurses' station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts. Observations on 8/07/2023, 8/08/2023, and 8/09/2023, of the medication storage rooms on Units A, G, and J, revealed that various medications were stored in tackle boxes located at the nurses' stations. The nurses' stations were not a locked area and did not always have nursing personnel present in the area. The tackle boxes were not stored in the secured medication room. The tackle boxes were not secured at the nurses' stations and could be easily removed from the area by unauthorized persons. During an interview on 8/09/2023, at 10:57 a.m. the Director of Nursing confirmed that medications in the tackle boxes were not safely secured in a locked medication storage room on Units A, G, and J. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after [CONDITION(S)]) as required for one of one residents reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility staff did not administer CPR to Resident R1 as required. This failure placed 58 of 132 residents (Residents R4-R62), that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Pennsylvania Orders for Life Sustaining Treatment/POLST reviewed by the facility on [DATE], revealed that A signed POLST form will stand as a written physician's order. Review of the facility policy entitled, Emergency Procedure-Cardiopulmonary Resuscitation/CPR reviewed by the facility on [DATE], revealed that The nursing supervisor will lead CPR .Begin CPR if the adult victim is unresponsive and not breathing normally .A licensed staff member who is certified in CPR shall initiate CPR unless there is a Do Not Resuscitate (DNR) order .Or there are obvious signs of irreversible death such as rigor mortis which is stiffening of the joints and muscles of a body. Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A POLST (Pennsylvania Orders for Life-Sustaining Treatment) dated [DATE], stated, FIRST follow these orders, THEN contact Physician, Certified Registered Nurse Practioner or Physician Assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the Certified Registered Nurse Practioner and Resident R1 and Section A revealed that CPR/attempt resuscitation was to occur when no pulse and no breathing were present. The facility Physician Orders that were discontinued on [DATE] (Resident R1's date of death ), identified Resident R1 as a Full Code (allows for all interventions needed to restore breathing or heart functioning). Review of documentation in Resident R1's chart on [DATE], (Resident R1's date of death ), revealed a nursing progress note at 6:06 a.m. identifying that the resident's blood pressure at 2:00 a.m. was ,d+[DATE] and at 4:00 a.m. was ,d+[DATE] (low blood pressure is lower than 90 millimeters of mercury ((mm Hg)) for the top number and lower than 60 mm Hg for the bottom number). In addition, intravenous fluids (fluids that go into the vein) were running as ordered by the physician on [DATE], at 4:00 p.m. that vitals were being done every four hours as ordered by the physician on [DATE], at 1:00 p.m., and that blood pressure medications were being held as ordered by the physician on [DATE], at 4:00 p.m. The only other nursing progress note on [DATE] was at 10:33 p.m. that stated the nurse aide had reported to the RN at 6:05 p.m. that Resident R1 was not breathing and he/she ceased to breathe (CTB) at 6:10 p.m. and the blood pressure summary with no blood pressure readings listed for [DATE]. During interviews on [DATE], at 10:55 a.m. and 1:30 p.m., the Director of Nursing (DON) revealed that he/she was the RN Supervisor on [DATE], second shift, 3:00 p.m. - 11:00 p.m. During the interview at 10:55 a.m. the DON stated that after Resident R1 CTB, Registered Nurse (RN) Employee E1 called him/her and said Resident R1 CTB and that he/she pronounced the death. The DON then asked RN Employee E1 about Resident R1's code status and was told that he/she was a Full Code and that CPR was not initiated because Resident R1 had already CTB. During the interview at 1:30 p.m., the DON stated that he/she couldn't recall hearing a page to go to A Unit STAT (immediately) and couldn't recall if he/she was on A Unit during/after Resident R1 CTB. During an interview on [DATE], at 2:45 p.m. Nursing Assistant/Aide (NA) Employee E2 stated that he/she was working on Unit A on [DATE], second shift, 3:00 p.m. - 11:00 p.m. and was picking up dinner trays around 5:30 p.m. when Resident R1 asked to be cleaned up because he/she was incontinent. NA Employee E2 came back to his/her room around 5:45 p.m. and noticed Resident R1 wasn't breathing right. He/she went out into the hall and yelled for help but a nurse didn't come. NA Employee E3 came and was helping find a nurse. During this time, NA Employee E2 kept going back into Resident R1's room and his/her breathing kept getting worse and he/she was cool to the touch. Around 6:00 p.m., Licensed Practical Nurse (LPN) Employee E4 went into Resident R1's room and Resident R1 stopped breathing and then RN Employee E1 entered into the room. RN Employee E1 assessed Resident R1 and stated that Resident R1 had CTB. During an interview on [DATE], at 3:28 p.m. RN Employee E1 stated that he/she was working on A Unit on [DATE], second shift, 3:00 p.m. - 11:00 p.m. RN Employee E1 was finishing his/her break around 6:00 p.m. and heard a page for the RN supervisor to go to A unit STAT. He/she returned to A Unit and was directed to Resident R1's room. RN Employee E1 revealed that Resident R1 had no heartbeat and was cold to the touch. He/she found out that Resident R1 was a Full Code but stated that he/she was already deceased so CPR was not initated. In addition, he/she stated that the RN Supervisor was on the floor for around five to ten minutes after Resident R1 CTB. During an interview on [DATE], at 11:00 a.m. NA Employee E5 stated that he/she was working on Unit A on [DATE], second shift, 3:00 p.m. - 11:00 p.m. and that Resident R1 came back to A unit around 3:30 p.m. from activities. Between 5:30 p.m. and 6:00 p.m., NA Employee E2 needed help and he/she went to Resident R1's room. Resident R1 was not breathing well and NA Employee E5 was holding his/her hand and noticed that it was cool to the touch. Around 6:00 p.m., RN Employee E1 and LPN Employee E4 were in Resident R1's room and assessed him/her. They went to get a stethoscope and to check the POLST. During this time, Resident R1 CTB. NA Employee E5 stated that the RN Supervisor pronounced the death. Review of Resident R1's death certificate identified the main cause of death as Cardiopulmonary Arrest on [DATE]. During an interview on [DATE], at 1:30 p.m. the DON revealed that if a resident is a Full Code and becomes unresponsive, CPR should be started and emergency medical services should be called immediately. The facility failed to promptly initiate CPR in accordance with the resident's wishes and professional standards of nursing to a resident who had requested CPR during the admission process, had a physician's order for CPR and had been identified as a FULL CODE, when finding the resident unresponsive, without a pulse or breathing and without clear clinical signs of death placing 58 other residents who had requested CPR be administered in the event that they were to suddenly become unresponsive and pulseless in Immediate Jeopardy. The Nursing Home Administrator was notified of the Immediate Jeopardy situation on [DATE], at 3:45 p.m. The immediate jeopardy template was given to the Nursing Home Administrator and an immediate action plan was requested. On [DATE], at 5:28 p.m. an acceptable immediate action plan was approved that included: When an unresponsive resident that is a Full Code and is not displaying signs of irreversible death, CPR will be initiated and [DATE] will be called. All Residents Code Status's will be audited by facility and identified in their medical records chart under Code Status tab. Staff will be educated on the location of that information in the residents chart. All Ward Clerks will be re-educated on documenting Code Status in residents electronic medical record. Staff education of above points will begin immediately with current shift and continue until all licensed staff are re-educated. On [DATE], during an onsite visit, the Immediate Jeopardy was lifted at 3:07 p.m. after ensuring the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(2)(e)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury and resulted in actual harm when the resident suffered a [CONDITION(S)] that required surgical intervention at a hospital for one of one residents reviewed (Resident R2). Findings include: Review of Resident R2's clinical record revealed an original admitted [DATE], with diagnoses that included a past traumatic brain injury, [CONDITION(S)], and [CONDITION(S)] disease (neurological disease that causes muscle tremors). Review of a facility policy dated January 6, 2021, entitled Using a Mechanical Lift for Transfers indicated that the staff were to refer to Physical Therapy orders for the staff required for transfers. Review of a Physical Therapy recommendation dated 9/3/19, directed the staff to transfer Resident R2 using a mechanical lift with the assistance of two staff members. The most recent quarterly Minimum Data Set (MDS-periodic assessment of resident care needs) assessment, dated 11/25/21, documented that Resident R2 required extensive assistance with two persons for transfers. A physician's order dated 12/14/21, directed that Resident R2 be transferred with the assistance of two staff members. Review of a care plan reviewed/revised on 1/12/21, also directed that Resident R2 be transferred with the assistance of two staff members using a mechanical lift. Review of information submitted by the facility dated 12/23/21, at 1:30 p.m., revealed that Resident R2 had a fall during a transfer with a mechanical lift. The report disclosed that during the transfer, Resident R2 released the lift handles and fell to the floor. The event report also revealed that two staff were required for the lift transfer, but that the resident was being transferred with only one staff when the fall and injuries occurred. Review of a physician's note dated 1/7/22, revealed that on 12/27/21, Resident R2 required hospitalization and surgery to repair a left [CONDITION(S)] that occurred during the fall from a lift during transfer on 12/23/21. The surgery included removal of hardware previously used to repair a prior [CONDITION(S)]. During an interview on 1/15/22, at 12:20 p.m., the Director of Nursing confirmed that Nurse Aide Employee E1 should have transferred Resident R2 with the assistance of two staff members rather than one. The facility failed to safely transfer Resident R2 using a mechanical lift with two staff members that resulted in actual harm of a left [CONDITION(S)]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/15/21, 9/7/21 28 Pa. Code 201.18(b)(1) Management Previously cited 10/15/21, 9/7/21 28 Pa. Code 201.18(e)(1) Management Previously cited 10/15/21 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 10/15/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/15/21

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide enteral nutrition (a controlled method for providing nutritional needs via tube feeding) in accordance with physician's orders [REDACTED]. (Resident R1) Findings include: The Face Sheet for Resident R1 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The rate of administration was to be 60 cc's per hour. Review of information dated 9/7/18, submitted by the facility, revealed that on 9/7/18, the day shift nurse initiated a six hour feeding interval, setting the total amount to be infused as 360 cc, but inadvertently, also set the hourly rate of infusion to 360 cc per hour instead of the physician ordered rate of 60 cc per hour. After an hour the tube feeding machine signaled that the feeding was complete and a different nurse restarted the tube feeding since it had not run for six hours, but failed to notice the incorrect rate. After an additional hour, the machine again signaled completion, at which time, the nurse realized that the rate of infusion was too fast. The resident then began to cough and vomit and was sent to the hospital for evaluation and treatment. Resident Progress Notes dated 9/7/18, revealed that Resident R1 was admitted for antibiotic therapy with a [DIAGNOSES REDACTED]. During an interview on 9/13/18, at 11:00 a.m. the Assistant Director of Nursing confirmed the above sequence of events and indicated that Resident R1 was returning from the hospital following treatment for [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/10/17, 01/12/17, 03/11/16 28 Pa. Code 201.18(b)(1) Management Previously cited 02/10/17, 01/12/17, 03/11/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management Previously cited 02/10/17, 01/12/17 28 Pa. Code 211.12(c) Nursing services Previously cited 03/11/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/30/18, 02/10/17, 01/12/17, 03/11/16