Every finding on record at Pleasant View Communities

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to provide residents access to grievance forms on one of three units observed (Third Floor); and failed to provide residents access to the right to file written grievances anonymously on three of three units observed (First, Second, and Third Floor). Findings include: Review of facility policy, titled Resident Grievances, last reviewed January 2025, read, in part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Grievances may be voiced in the following forums. Verbal complaint to a staff member or Grievance Official. Written complaint to a staff member or Grievance Official. Written complaint to an outside party. Verbal complaint during resident or family council meetings. Via the company toll free Customer Service Line (if applicable). A grievance may be filed anonymously.During a group interview with Residents 2, 6, 37, and 73 on July 23, 2025, at 9:59 AM, all four residents revealed they were not sure how to file a grievance, including how to file one anonymously.Observation on the Second-Floor unit on July 23, 2025, at 10:18 AM, revealed some grievance forms attached to a bulletin board. There was no designated box or folder, etc. to put the grievances in if residents would prefer to file a grievance anonymously. Another posting detailed the information for the Grievance Official and stated, If you have any concerns, please forward them to our social workers or contact the grievance official as listed above, thank you.Interview with Employee 1 (Nurse Aide) on July 23, 2025, at 10:18 AM, revealed she is not aware of where residents would put a grievance if they wanted to file anonymously but that they could bring it to Human Resources. Observation in the First-Floor unit on July 23, 2025, at 10:27 AM, revealed some grievance forms in a folder attached to a bulletin board. The folder had instructions on it that stated, If you have a concern, please complete the top section of the form and return it to social services, the Registered Nurse supervisor, or at any nurses station, thank you!During an interview with the Nursing Home Administrator (NHA) on July 23, 2025, at 10:37 AM, she revealed that the process for residents to file a grievance anonymously would be to contact herself or a social worker privately. Observation in the Third-Floor unit on July 23, 2025, at 10:39 AM, revealed a bulletin board that did not contain grievance forms. Employee 2 (Social Worker) then went to get blank grievance forms in a drawer in the locked nurse's station. Further observation on the unit failed to reveal a designated box or folder, etc. to put the grievances in if residents would prefer to file a grievance anonymously. Interview with the NHA on July 23, 2025, at 10:39 AM, revealed the forms are usually kept on the bulletin board and she is unsure as to why they were not there. During an interview with Employee 2 on July 23, 2025, at 10:41 AM, she revealed the process for residents to file a grievance anonymously would be to contact herself or the grievance official, and if they wanted it to be anonymous, they would not share who the grievance came from with other staff members; or residents can put their grievance in an envelope and hand it a staff member to give to the grievance official or herself. During a follow up interview with the NHA on July 23, 2025, at 10:54 AM, she revealed the facility was going to purchase drop boxes for the units so that residents can file written grievances anonymously, and she would expect residents to have the opportunity to file grievances anonymously. 28 Pa code 201.18(b)(2)(3) Management28 Pa code 201.29(a) Resident rights

Based on surveyor observation, facility policy, and staff interview, it was determined that the facility failed to store schedule IV-controlled medication in a separately locked, permanently affixed compartment for one of three (500 west medication storage room refrigerator) areas observed. Findings Include: Review of facility provided policy, Controlled Medications Orders, revised September 17, 2013, revealed, Medications included in the DEA classifications as scheduled II thru V and are considered controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in the facility. The facility failed to provide any more specific information regarding how the medication would be stored. Observation of the 500 west medication storage room refrigerator on July 31, 2024, at 10:00 AM, revealed two 30 ml bottles of 2 mg/ml Lorazepam (sedative medication and schedule IV-controlled substance). The two bottles of Lorazepam were in the main part of the refrigerator and not secured in a separately locked, permanently affixed compartment in any way. Interview with Director of Nursing on August 1, 2024, at 11:35 AM, revealed that the Lorazepam should have been kept in a separate locked container inside of the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety on the spice rack in the main kitchen, in three of three nourishment pantry refrigerators, and in one kitchenette refrigerator. Findings include: Review of facility policy, Food Storage Chart, no date, read, in part, butter should be stored in the refrigerator and is good for four days once removed from the master case, and commercially prepared nutritional supplements should be used within seven days once thawed. Observation on the spice rack in the main kitchen on July 29, 2024, at 9:32 AM, revealed the following items were not labeled to identify contents or date marked: one metal pan containing a red colored spice blend with a black plastic spoon inside; one plastic container with a red colored spice blend inside; and one metal pan containing roux (a cooked flour and butter mixture use for thickening liquid). During an interview with Employee 2 (Assistant Manager of Dining Services) on July 31, 2024, at 9:32 AM, it was revealed that the pan of roux didn't require refrigeration, the red spices were made in-house, and all the aforementioned items should've been labeled and date marked. Observation on July 29, 2024, at 9:52 AM, on the 500 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: nine chocolate nutritional drinks and 14 vanilla nutritional drinks. Observation in the kitchenette refrigerator on July 29, 2024, at 9:53 AM, revealed one unopened plastic bag of thawed non-dairy topping was not date marked with a thawed or use by date. During an interview with Employee 2 on July 29, 2024, at 9:55 AM, it was revealed that each carton of nutritional drink and the non-dairy topping should be date marked when remove from the freezer. Observations on July 29, 2024, at 10:02 AM, on the 400 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: 18 vanilla nutritional drinks and 12 chocolate nutritional drinks. Observation on July 29, 2024, at 10:12 AM, on the 300 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: three chocolate nutritional drinks and nine vanilla nutritional drinks. During an interview with the Nursing Home Administrator on August 1, 2024, at 10:30 AM, the surveyor reviewed concerns with labeling and dating of items on the spice rack and in the refrigerators in the kitchenettes on all three neighborhoods. No further information was provided. 28 Pa code 211.6(f) - Dietary Services

Based on staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance designed to identify possible communicable disease or infection for three of 10 months reviewed (October 2023, November 2023, and December 2023). Findings include: A review of the facility policy, titled Infection Preventionist, last reviewed May 21, 2024, read, in part, the Infection Preventionist will Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff and visitors. The facility's monthly infection control logs for October 2023 through December 2023 were unable to be provided by the facility. An interview with the Director of Nursing (DON) and Nursing Home Administrator on August 1, 2024, at 9:46 AM, revealed the facility's former DON did not complete the line listing during October 2023, November 2023, and December 2023 to track resident disease or infection. 28 Pa Code 201.14(a)(c) Responsibility of licensee 28 Pa Code 211.1(a)(c) Reportable diseases

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered the pneumococcal vaccine as required for one of five residents reviewed (Resident 56). Findings include: A review of the facility's policy, titled Pneumococcal Conjugate Vaccine, recently revised June 12, 2024, read, in part, All residents should be offered the pneumococcal conjugate vaccine to aid in preventing pneumococcal infections (i.e. pneumonia). The policy continued, Prior to or upon admission, residents should be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, should be offered the vaccination within thirty (30) days of admission to the community unless medically contraindicated or the resident has already been vaccinated. Also, Before receiving the pneumococcal vaccine, the resident or resident representative should receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education should be documented in the resident's medical record. A review of Resident 56's clinical record revealed an admitted [DATE]. According to Resident 56's immunization documentation, the facility received historical data reflecting Resident 56 received the vaccine on April 10, 2024. Further review of Resident 56's clinical record revealed no documentation the facility provided education on the risks and benefits of the vaccine entered into the Resident's clinical record. An interview with the Director of Nursing on August 1, 2024, at 9:56 AM, confirmed the facility could not locate any documentation of the Resident or Resident Representative being provided education regarding the risks/benefits of receiving or refusing the vaccine in the clinical record. 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for two of five residents reviewed (Residents 16 and 56). Findings include: A review of the facility's policy, titled Covid-19 Vaccine for Residents, effective June 1, 2021, read, in part, All residents should be offered the COVID-19 vaccine to aid in prevention and transmission of COVID-19 infections. The policy continued, Before receiving the COVID-19 vaccine, the resident or resident representative should receive information and education regarding the benefits and potential side effects of the covid vaccine. Provision of such education should be documented in the resident's medical record. Also, In situations where COVID-19 vaccination requires multiple doses, the resident, the resident representative is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. A review of Resident 16's clinical record revealed an admitted to the facility on [DATE]. Further review of the clinical record revealed Resident 16's Power of Attorney (POA) refused the administration of the COVID-19 vaccine to Resident 16. Further review of Resident 16's clinical record revealed no documentation of the Resident or POA provided education regarding the risks/benefits of the vaccine. A review of Resident 56's clinical record revealed an admitted to the facility on [DATE]. Further review of the clinical record revealed Resident 56's POA refused the administration of the COVID-19 vaccine to Resident 56, Further review of Resident 56's clinical record revealed no documentation of the Resident or POA provided education regarding the risks/benefits of the vaccine. An interview with the Director of Nursing on August 1, 2024, at 9:56 AM, confirmed the facility could not locate any documentation of the Resident or Resident Representative being provided education regarding the risks/benefits of receiving or refusing the Covid-19 vaccine in those Resident records. 28 Pa. Code 201.18(b)(1) Management

Based on observation and staff interview, it was determined that the facility failed to ensure each resident is notified of the right to file grievances by contacting the grievance official with whom a grievance can be filed, his or her name, business address (mailing and email) and business phone number for three of three resident areas reviewed (300 Hall, 400 Hall, and 500 Hall). Findings Include: Observations on October 11, 2022, and October 12, 2022, on the 300, 400, and 500 Halls, revealed no postings or areas displaying the facility's identified Grievance Official, including his or her contact information, for resident use and review. An interview with the Nursing Home Administrator (NHA), on October 13, 2022, at 10:12 AM, revealed the facility has updated its Grievance Official information, and the NHA has now been identified as the facility's Grievance Official. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (3) Management

Based on observation and staff interview, it was determined that the facility failed to ensure each resident the right to examine the results of the most recent survey conducted by Federal or State surveyors for three of three resident areas observed (300 Hall, 400 Hall, and 500 Hall). Findings Include: Observations on October 11, 2022, and October 12, 2022, on the 300 and 400 Halls revealed no postings or areas displaying the facility's most recent survey results for resident review. An observation on the 500 Hall, with the Director of Nursing (DON), on October 13, 2022, at 10:49 AM, revealed a folder containing information that did not include the facility's most recent survey results. An immediate interview with the DON revealed the facility plans to update the information with the most recent survey results for resident access in all areas. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (3) Management

Based on observations, interviews, and policy reviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety in the dietary department and in two of two unit kitchenettes. Findings include: Review of facility policy titled Labeling and Dating dated March 2010, revealed: 1) All food items must be labeled with either a manufacturer or handwritten label; and 7) All bulk meat products will be labeled with a pull date and utilized within three days. Review of facility policy titled Outside Food or Beverages dated September 2, 2020, revealed 4) All foods and beverages brought into the facility should be provided in a sealed container, labeled with the resident's name, and dated. Observation in the main kitchen on October 11, 2022, at approximately 9:47 AM, revealed a bag of frozen meatballs in the Cook's 4 cooler, with no label indicating date pulled or use-by date. Employee 2 confirmed that there was no date present. Observation on October 11, 2022, at approximately 10:10 AM, of the 500 unit pantry freezer, revealed an almost empty carton of ice cream labeled with a resident's name, but no date and no manufacturer expiration date noted. Employee 2 confirmed there was no date present, discarded the container, and indicated the ice cream should have been dated. Observation on October 11, 2022, at approximately 10:20 AM, of the 400 unit kitchenette dish room revealed Employee 3 removing clean dishes from the dishwasher with no gloves in use. Employee 2 indicated that Employee 3 should have been wearing gloves to remove clean dishes from the dishwasher and educated Employee 3 at that time. Employee 3 stopped, washed hands, and applied gloves. During an interview with Nursing Home Administrator (NHA) on October 12, 2022, at approximately 11:40 AM, the NHA indicated that she would expect staff to follow policies for labeling and dating and wearing of gloves when handling clean dishes. Observation on October 12, 2022, at approximately 12:16 PM, of tray line service on 400 unit, revealed Employee 3 serving food onto plates for residents. Employee 3 had a beard that was exposed and the beard covering was noted to be down off the beard, dangling around the Employee's neck. Employee 4 was present for this observation and confirmed that Employee 3 should have had the beard covering over their beard. Employee 3 removed Employee 2 from the tray service line, and had them apply their beard covering, remove gloves, wash hands, and apply clean gloves before returning to tray service line. Email communication received from NHA on October 12, 2022, at 3:51 PM, indicated that the meatballs had been pulled from the box to thaw out for the meal service; the ice cream had been discarded; staff have been educated on including the residents' name and date on the containers; and that Employee 3 was on day one of their first shift, and they were provided additional education and training. Email communication received from NHA on October 12, 2022, at 4:59 PM, the NHA confirmed again that she would expect food items to be labeled and dated, and that she would expect Employees to follow sanitary practices for food safety throughout the facility. 28 Pa code 211.6(b)(d) - Dietary Services

Based on review observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide respiratory services for one of 20 residents reviewed (Resident 3). Findings include: Review of Resident 3's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 3 on October 12, 2022, at 9:55 AM, revealed the Resident lying in bed, eating breakfast, receiving supplemental oxygen via nasal canula. Further observation revealed that the oxygen tubing was not labeled with a date that they were put in use. Review of facility provided policy titled Oxygen administration effective August 12, 2013, revealed, Label all tubing and masks with date and change as ordered. Discard used supplies into designated containers. Review of Resident 3's Care Plan failed to reveal any plan of care related to supplemental use. During an interview with the Director of Nursing on October 12, 2022, at 12:47 PM, it was revealed that the expectation is that the oxygen tubing would be dated and that the facility policy would be followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure the development of a comprehensive person-centered plan of care based on results of the comprehensive assessment for one of three residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and weakness (reduced strength in one or more muscles). Review of Resident 1's Minimum Data Set (MDS- periodic assessment of resident care and service needs) dated March 30, 2022, revealed in Section C -Cognitive Patterns -Subsection C1000 the resident is marked as severely impaired. The same MDS Section G -Functional Status Subsection 1A Bed Mobility the resident was marked as total dependence and physical assist of two. Review of the care plan that was in place at the time of Resident 1's fall on May 14, 2022 revealed the resident was at risk for falls R/T poor safety awareness, increased muscle weakness and mobility requiring hoyer assistance with transfers. The care plan had several interventions related to this risk. Review of Resident 1's interdisciplinary plan of care revealed no interventions developed to address Resident 1's bed mobility assistance concerns noted in the MDS of March 30, 2022. An interview with the Director of Nursing on June 16, 2022, at 2:06 PM confirmed the facility had not developed the bed mobility care plan after the assessment but had recently added the care plan to the resident's record. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.11 (d) Resident care plan

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure the Minimum Data Set (MDS-periodic assessment of resident needs) accurately reflected the restraint status of four out of five resident records reviewed (Resident #7, Resident #29, Resident #60, and Resident #64). Findings include: Observation on (MONTH) 7 and (MONTH) 8, 2020, of Resident #29's bed revealed a ¼ bed rail located on the left side, near head of the bed. Review of Resident #7's clinical record revealed a quarterly MDS assessment dated (MONTH) 30, 2019 which indicated in Section P0100 Physical Restraints that bed rail was coded a 2. Used Daily. Review of Resident #7's clinical record revealed a bed rail assessment dated (MONTH) 28, 2019 which indicated resident currently used side rail/assist rail for positioning. Continued review of assessment revealed resident uses bed rail/assist rail to Turning side to side. Moving up and down in bed. Holding self to one side. Pulling self from laying to sitting position. Bed rail/assist will assist in: improving balance support self. Exiting bed more safely, entering bed more safely. Entering bed more safely. Review of Resident #29's clinical record revealed a quarterly MDS assessment dated (MONTH) 15, 2019 which indicated in Section P0100 Physical Restraints that bed rail was coded a 2. Used Daily. Review of Resident #29's clinical record revealed a bed rail assessment dated (MONTH) 5, 2019 which indicated resident currently used side rail/assist rail for positioning. Continued review of assessment revealed resident uses bed rail/assist rail to pull self from laying to sitting position. Bed rail/assist will assist in: improving balance support self exiting bed more safely entering bed more safely Review of Resident #60's clinical record revealed a quarterly MDS assessment dated (MONTH) 30, 2019 which indicated in Section P0100 Physical Restraints that bed rail was coded a 2. Used Daily. Review of Resident #60's clinical record revealed a bed rail assessment dated (MONTH) 30, 2019 which indicated resident currently used side rail/assist rail for positioning. Continued review of assessment revealed resident uses bed rail/assist rail to Turning side to side. Moving up and down in bed. Holding self to one side. Pulling self from laying to sitting position. Review of Resident #64's clinical record revealed a quarterly MDS assessment dated (MONTH) 2, 2019 which indicated in Section P0100 Physical Restraints that bed rail was coded a 2. Used Daily. Review of Resident #64's clinical record revealed a bed rail assessment dated (MONTH) 5, 2019 which indicated resident currently used side rail/assist rail for positioning. Continued review of assessment revealed resident uses bed rail/assist rail to Turning side to side. Moving up and down in bed. Holding self to one side. Pulling self from laying to sitting position. Bed rail/assist will assist in: improving balance support self. Exiting bed more safely. Entering bed more safely. Interview on (MONTH) 8, 2020 at approximately 1:45 p.m. with licensed Employee E4, who indicated that the bed mobility aide; a ¼ side rail does not restrict movement of body by resident(s) therefore not considered a restraint by staff. Employee E4 revealed that resident(s) use the ¼ side rail as a mobility device to aide in bed mobility and stability for transfers. Interview conducted on (MONTH) 9, 2020 at approximately 11:40 a.m. with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing when the above information was presented regarding incorrect coding in the MDS assessment of physical restraints when used as mobility devices. 28 Pa Code 211.5(f) Clinical Records 28 Pa Code 211.12(d)(5) Nursing Services Previously cited on 11/20/18

Based on review of information submitted by the facility, facility documentation and staff interview it was determined the facility failed to allow access for visitors for one of 24 residents reviewed. (Resident #36) Findings include: Review of information submitted by the facility on (MONTH) 16, 2019, revealed Resident #36's visitor was overheard saying to his family member that the water here is poison. When the Nursing Assistant handed water to another resident the resident stated, it looks like they put something in it, Resident #36's visitor responded, she hit the nail on the head. An investigation was completed by the facility. Review of facility investigation documentation revealed that on (MONTH) 19, 2019 at 10:30 a.m. a telephone interview with Employee E7 was conducted. That interview revealed that on (MONTH) 16, 2019 Resident #36's visitor arrived on the unit around 4:30 p.m. and left around 10:30 p.m. and while there was observed screaming at the staff saying, {I want all of her food now}. Resident #36 was finish up the soup and was not upset by the comments. Resident #36's visitor was told by a staff member that we are to give her one thing at a time and Resident #36's visitor said, {I am overriding this}. When Resident #36 was being placed back into bed on (MONTH) 16, 2019 Resident #36's visitor yelled at the staff {you can't put her head down she has back pain.} At the end of the evening when Resident #36 was in bed Resident #36's visitor sat at the desk in the TV lounge and just watched what everyone else as doing. I made them staff uncomfortable. Resident #36's visitor makes comments how we {drug our residents} and said {you're trying to feed someone that is comatose}. Another statement was obtained from Employee E8 on (MONTH) 19, 2019 stating while I was passing out water, when I handed another resident hers, she said that it looked like {they put something in it} and Resident #36's visitor said, {she's right, she hit the nail on the head} Resident #36's visitor said {the water here is poison}. Employee E8 also stated Resident #36's visitor brings in a glass bottle that he calls his root juice that he puts in her coffee and that Resident #36's visitor has raised his eyebrows at another staff member flirtatiously. Another statement was obtained from Employee E9 on (MONTH) 19, 2019 via telephone stating she was not there on (MONTH) 16 but she was witness to Resident #36's visitor making fun of another Nursing Assistant in the dining room. When they ask to toilet Resident #36, Resident #36's visitor will often attempt to come with them or refuse toileting. Resident #36's visitor brings a glass bottle with stuff in it. He often offers to go back to the kitchen and I always offer to get things and he always says, {I got it}. He makes me uncomfortable as he wiggles his eyebrows at me like he is checking me out. Another statement was obtained from Employee E10 on (MONTH) 19, 2019 stating one time Resident #36's visitor brought in ice cream and put it under her eye and Resident #36 said {oh oh} and Resident #36's visitor said {is it hot} Resident #36 said {yes} and Resident #36's visitor said {just give it a minute} so I've learned to just not give meds in front of him. Another statement obtained from Employee E11 on (MONTH) 19, 2019 stated I worked a double one night and all he did was tell us he we do everything wrong. I can't really remember specifics, but he is just so negative. A letter sent via certified mail to Resident #36's visitor, on Pleasant View Retirement Community letterhead, dated (MONTH) 20, 2019, states This letter is to confirm our telephone conversation on Monday, (MONTH) 19, 2019 notifying you that you are prohibited from trespassing or contacting Pleasant View Retirement Community, located at 544 N. Penryn Road, Manheim, PA . If violation occurs, law enforcement will be immediately notified. Sincerely, The management of Pleasant View Retirement Community. Interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on (MONTH) 9, 2020 at approximately 10:30 a.m. revealed Resident #36's visitor is still not permitted to visit Resident #36. The DON and NHA were asked to present any documented evidence of a history of this behavior from Resident #36's visitor and interventions they have implemented to correct the behaviors. Review of clinical notes provided by the NHA and DON revealed a nursing entry on (MONTH) 28, (YEAR) at 5:36 p.m. stating Resident #36's visitor was present during the administration of a Tylenol. Resident #36's visitor began yelling, waving his arms and moving towards the LPN. RN called to assist at 4:55 p.m., observed Resident #36's visitor waving his arms around and yelling I'm flipping out. Resident #36's visitor states he was unaware resident #36 was on Tylenol and yelled I'm against it it's sedating and that he doesn't agree with the drugs that are being given to resident #36. Further review of clinical notes provided by the DON and NHA revealed a nursing entry on (MONTH) 1, (YEAR) at 9:56 p.m. stating Resident #36's visitor was in and left and stated he's not in his right mind, he walked here from New Jersey and he is going to kill himself or someone else spoke with Resident #36 who stated he has everyone snowed, he's a dead head, it's my fault, it's always my fault Spoke with Resident #36's power of attorney about the situation and stated I talked to resident #36's visitor and asked them not to tell resident #36 she is going home, I will call resident #36 as well. A social services progress note, dated (MONTH) 8, (YEAR) at 10:52 a.m. stated resident #36's visitor is known to be verbally aggressive and short tempered with staff during his Sunday visits There was no documented evidence provided to the surveyor of interventions the facility put into place prior to being denied all visitation rights. There was no documented evidence of behaviors from Resident 36's visitor from (YEAR), (YEAR), or 2019 prior to this incident on (MONTH) 19, 2019 and what was mentioned in the statements above. The facility removed the resident's rights to allow visitation from a visitor without showing documented evidence that the visitor was a clear threat to residents and staff and after the attempt of other interventions to change behaviors. Pa Code 201.18 (b)(2) Management Pa Code 201.29 (a)(j) Resident Rights Pa Code 201.30 (a) Access requirements

Based on review of personnel files as well as staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of five nurse aides reviewed (Employee E5 and Employee E6). Findings include: Review of the facility's nurse aide education records for the past 12 months revealed that there was no documented evidence that Employee E5 and Employee E6 received performance reviews at least once every 12 months. Interview conducted with Nursing Home Administrator and Director of Nursing on (MONTH) 9, 2020 at approximately 10:40 a.m. when the above information was presented. Nursing Home Administrator confirmed the facility does not have documentation of annual performance reviews for the two nurse aide employees. 28 Pa Code 201.20(a)(c) Staff Development

Based on review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure that adequate supervision was provided to prevent accidents for one of 15 residents reviewed (Resident #37). Findings include: Review of facility policy and procedure entitled Falls and Fall Risk, revised (MONTH) 12, (YEAR) revealed the purpose of the policy is to provide guidelines for assessing a resident after a fall and to assist the staff in identifying causes of the fall. Further review of this policy revealed Immediately after a fall and to be concluded within 72 hours, the nursing staff should try to identify probably causes of the fall. Review of Resident #37's [DIAGNOSES REDACTED]. Review of Resident #37's Admission MDS dated (MONTH) 16, (YEAR) revealed Resident #37's BIMS score was 2 indicating severe cognitive impairment. Further review of this MDS revealed Resident #37 required extensive assistance of two staff members for transfer; extensive assistance of two staff members for ambulation in resident's room. Review of Resident #37's active plan of care dated (MONTH) 9, (YEAR) revealed resident was at risk for falls related to the presence of a left artificial hip joint, history of falls, impaired mobility, muscle weakness, poor safety awareness, impulsiveness, cognitive impairments and attempts to pick items up off the floor. Interventions on the active plan of care included reminding the resident to call for assistance before getting out of bed; assess resident's risk for falls and implement fall prevention plan; resident is not to be left unattended when in bathroom toileting and offer resident an activity of preference when sitting at dining room table following meals. Review of Resident #37's documentation provided by the facility to the State Agency revealed between (MONTH) 1, (YEAR) and (MONTH) 16, (YEAR), revealed that Resident #37 sustained twenty falls during this time period . Further review of this documentation revealed the following: on (MONTH) 1, (YEAR) at 10:45 a.m. Resident #37 was left unattended in the bathroom and was found on the floor of the resident's room; (MONTH) 4, (YEAR) at 10:20 p.m. Resident #37 was found on the floor of the resident's room with a recommendation to continue the current plan of care to prevent injury; (MONTH) 7, (YEAR) at 10:55 p.m. resident was found on the floor between bedroom and bathroom with baseline confusion and weakness needed to void and got up by herself; (MONTH) 10, (YEAR) at 2:30 a.m. resident was found on floor near room door said that (resident) needed air staff education - ensure 02 (oxygen) is applied when placing into bed; (MONTH) 11, (YEAR) at 4:50 a.m. was found on the floor in the foyer area of the room cognition of resident - jeopardizes safety through actions; (MONTH) 11, (YEAR) at 3:20 p.m. found in dining room by CNA sitting in front of door to go to outside corridor poor safety awareness; (MONTH) 17, (YEAR) at 9:30 a.m. resident was at dining room table sitting in wheelchair finishing breakfast; stood up, lost balance and fell to floor standing up by self, poor balance; does not remember to call/wait for help; (MONTH) 23, (YEAR) at 11:30 p.m. resident sitting on floor of bathroom in front of toilet poor safety awareness needed to use bathroom; (MONTH) 27, (YEAR) at 11:50 p.m. found on floor in front of toilet; (MONTH) 3, (YEAR) at 10:40 a.m. found on floor in living by staff questionable boredom with need for activity between meals; (MONTH) 18, (YEAR) at 1:00 a.m. found on floor of room continue with current P[NAME] (plan of care) to prevent injury lack of safety awareness; (MONTH) 17, (YEAR) at 8:55 p.m. found resident sitting in front of wheelchair on floor next to bed; (MONTH) 12, (YEAR) at 2:15 p.m. found on floor of hallway bathroom with a 3 cm (centimeter) x 3 cm hematoma to left posterior (back) head continue with current P[NAME] to prevent injury; (MONTH) 19, (YEAR) at 4:00 p.m. dietary staff member alerted staff that resident was on floor in small area of dining room believe resident stood up in an effort to manually turn wheelchair around; (MONTH) 31, (YEAR) at 6:40 p.m. found on floor in bedroom coming back from bathroom trying to get to bed transferring unassisted from wheelchair into bed - nonadherent to use of call bell for assistance; (MONTH) 27, (YEAR) at 10:16 p.m. found on floor of bedroom continue with current P[NAME] to prevent injury; (MONTH) 11, (YEAR) at 5:20 a.m. found on floor of bedroom continue with current P[NAME] to prevent injury; (MONTH) 23, (YEAR) at 11:05 p.m. found on floor inside entry doors of unit lights in hallway dimmed for HS hours resident did not ask staff for assistance - aide was around corner from where resident was found just before fall; (MONTH) 1, (YEAR) at 3:55 p.m. found on floor near door of room resident is non-compliant and self-transfers; (MONTH) 16, (YEAR) at 10:20 a.m. found on floor of dining room in front of windows stated was leaning forward in wheelchair in attempt to pick crumbs up off floor and fell forward out of chair. Observation of Resident #37 during all days of the survey revealed that the resident was alone in the room when not engaged in eating or an activity. The facility failed to consistently supervised and monitored Resident #37 to ensure the resident's safety. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services Previously cited 11/14/17 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/14/17

Based on review of documentation submitted by the facility and staff interview, it was determined that the facility failed to report allegations of sexual abuse to the Department of Aging for one of three residents reviewed. (Resident 1) Findings include: Review of the Older Adults Protective Services Act (OAPSA), mandates reporting requirements on suspected abuse. Any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local Area Agency on Aging and licensing agencies. If the suspected abuse is sexual abuse, serious physical injury, serious bodily injury, or suspicious death as defined under OAPSA, the law requires additional reporting to the Department of Aging and local law enforcement. Review of documentation submitted by the facility revealed Resident 1 made an allegation of sexual abuse on (MONTH) 14, (YEAR). Further review of the documentation revealed that the facility did not notify Pennsylvania Department of Aging. Interview with the Nursing Home Administrator on July19, (YEAR) at 9:47a.m. confirmed that the Pennsylvania Department of Aging was not notified of the sexual abuse allegations made by Resident 1. 28 Pa. Code: 201.14 (a)(c) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(d) Management.

Based on observations and staff interview, it was determined that the facility failed to provide an environment free from hazards on three out of five units by assuring that windows in resident areas were secure. ( 100 unit, 200 unit and 300 unit). Findings include: During an initial environmental tour of the 300 unit on November 8, 2017 at approximately 12:45 p.m. Employee E6, a nursing assistant, was observed in the dining room while approximately ten residents still remained at the table or in the sitting area after the luncheon meal. Employee E6 was talking with a resident's husband who was concerned about his car in the parking lot. Employee E6 went over to the windows at the end of the dining room and raised the window to his eye level to look out on the parking lot (2 floors up). The resident's husband was standing behind Employee E6 as he was observed closing the window. It wanoted that these two windows at the end of the room did not have screens in them. The other windows lining the entire wall and on the other end of the dining room did have screens. Interview with unit manager, licensed nurse, Employee E7, on November 8, 2017 at approximately 1:10 p.m. and was not aware of who montiored the windows or how the windows could be kept from fully opening but would contact the maintenance department. Approximately 15 minutes later, Employee E7 demonstrated that by pushing a plastic toggle-like device on the inside window frame, the device would, when activated, prevent the window from being opened more than 6 inches. These devices could be activated or deactivated by pushing them in to become flush with the frame. During an expanded environmental tour of the 100 unit on November 8, 2017 at approximately 2:50 p.m. surveyor noted that four of the dining room windows did not have the locking mechanism engaged. Survey noted that the windows did not have the safety latch preventing the window from rising about six inches engaged. During a continued, expanded environmental tour of the 200 unit on November 8, 2017 at approximately 3:20 p.m., by the survey team the windows in all resident rooms were examined . Upon inspection of the window frames, could not identify a gold lock mechanism to prevent the window from being fully opening. Plastic toggles were in window frames, but safety feature not engaged. Further examination noted the windows in the common area titled living room at the end of the hall had a series of 9 windows. Upon further examination, eight of nine windows opened fully. Plastic toggles were in window frame, but safety feature not engaged. During an expanded environmental tour of the 300 unit on November 8, 2017 at approximately 2:55 p.m. the windows in residents rooms were found to have gold locks on the windows. Rooms 316, 319, and 323 were examined by the surveyors and found the gold lock mechanism to be disengaged and the windows were able to be opened fully. In the living room at the end of the hallway on the 300 unit the eight windows in the room had no gold lock mechanisms. The plastic safety toggle on each window was disengaged, and each window was able to be opened fully. Interview on November 8, 2017 at approximately 3:05 p.m. with licensed staff employee, Employee E7 revealed they were unaware of who had keys to open windows. Interview with non-licensed employee, Employee E8 revealed that the housekeepers had keys to the windows for monthly cleaning. Interview with Nursing Home Administrator and Director of Nursing on November 8, 2017 at approximately 3:40 p.m. revealed that these safety concerns on the windows needed to be addressed to provide safe environment for all residents. F323 483.25(d) Accidents Previously cited 12/28/2016 28 PA Code 201.14(a) Responsibility of licensee Previously cited 12/28/2016 28 PA Code 201.18(b)(1) Management Previously cited 12/4/2016; 12/28/2016

Based on review of the clinical record and interview with facility staff, it was determined that the facility failed to coordinate life care decisions including cardio [MEDICAL CONDITION] resuscitation as an interdisciplinary team with one of 24 residents reviewed to ensure that the medical orders reflected the resident's choices. (Resident CL2) Findings include: Review of Resident CL2's [DIAGNOSES REDACTED]. blood) and obstructive sleep apnea (temporary absence of breathing during sleep secondary to upper airway obstruction). Review of the Resident CL2's Individual Instruction for Health Care Decisions signed on [DATE] on admission revealed a wish by the resident to be a no code ( in case of loss of vital signs, resident does not wish any efforts to revive him to life). On the resident's readmission to the facility on [DATE] following a hospital stay, the resident's daughter signed a No Code Agreement. Review of the Resident CL2's 14- day MDS (Minimum Data Set: a periodic assessment of the resident's care needs) revealed that the resident was a ,[DATE] on the BIMS (Brief Interview of Mental Status) indicating that the resident was cognitively intact in reasoning ability. Further review of Resident CL2's clinical record revealed that the resident returned from a hospital stay on [DATE]. The attending physician visited the resident on [DATE]. Review of the physician's progress note dated [DATE] (transcribed [DATE]) indicated that the resident and physician had a discussion concerning 'do not resuscitate' and 'do not hospitalize.' The physician stated in his note that he did see the form signed by the daughter for do not resuscitate however he stated that the resident was not sure that was what the resident wanted and since the resident was alert and oriented, that decision will be rescinded currently. The physician instructed the resident to further discuss this with his family and let the staff know in the next day or two of his decision. Review of Resident CL2 [DATE] physician's orders [REDACTED]. Review of the CL2's clinical notes dated [DATE] revealed that at 6:15 p.m. the nurse was called to the resident's room after staff heard the resident calling for help. The resident then quickly became unresponsive and expired. An interview with the attending physician on [DATE] at approximately 2:15 p.m. revealed that he felt that the resident's DNR status should have been pursued further. During an interview on [DATE] at approximately 2:00 p.m., the Director of Nursing stated that it was her impression that the resident may have wanted to change his mind about his care. An interview with the unit manager, Employee E4, a licensed nurse on [DATE] at approximately 2:30 p.m. revealed that after the physician's notes are dictated, transcribed and returned to the unit that they are not usually read by staff and he was not sure that staff accompanied the physician on rounds with this patient the day this discussion took place. The health care team failed to clarify and communicate the resident's choices regarding care and services to be provided when circulatory and /or respiratory function had ceased. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(3) Nursing services 28 Pa Code 211.12(5) Nursing services Previously cited [DATE]

Based on clinical record review and staff interview, it was determined that the facility failed to provide regular oral hygiene assistance for dependent residents for four out of 24 residents reviewed. (Residents G4, H8, I2 and J12) Findings include: Review of Resident H8's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated June 13, 2016, included [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE], revealed that the resident required extensive assistance of one person for personal hygiene. Review of dental consultation record dated October 14, 2016, stated it appears that no home care (brushing/flossing) is taking place. Patient must have assistance with brushing and flossing at least twice a day. Do not leave it up to resident to brush her teeth. Review of Resident G4's [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment completed on October 12, 2016 indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 1 out of 15 indicating severe cognitive impairment. Treatment completed by the dental hygienist on September 12, 2016 revealed that the resident was found to have heavy food debris and heavy plaque (an accumulation of microorganisms that builds up around gums and teeth which contributes to decay and gum disease/tooth loss). The assessment also revealed that the resident was coded a 1/2 for ADL asisst (activities of daily living) which indicated that the resident require supervision and the physical asistance of one person for oral hygiene. Review of Resident I2's [DIAGNOSES REDACTED]. The resident's annual MDS assessment completed on September 19, 2016 indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 4 out of 15 indicating severe cognitive impairment. Further review of this assessment revealed that the resident require the extensive assistance of one staff member for effective oral care. An examination completed by the dentist on August 30, 2016 indicated that the resident had moderate to heavy plaque on the teeth. Review of Resident J12's [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment dated [DATE] indicated that the resident was coded a 3/2 for ADL assistance revealing that the resident would require the extensive asistance of one staff member to complete oral care. In addition, the resident was identified in the BIMS score as a 6/15 indicating severe cognitive impairment and would require assistance and direction to initiate and complete this activity of daily living. The dental visit dated September 12, 2016 identified that the resident had heavy food debris and moderate calculus (mineralized dental plaque) in her mouth. The facility failed to assist dependent residents with mouth care needs which resulted in poor oral hygiene as identified by dental professionals during examinations. These findings were presented to the Nursing Home Administrator on December 28, 2016 at 2:15 p.m. 28 PA Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/9/2015

Based on clinical record review, facility documentation and staff interview, it was determined that the facility failed to provide adequate supervision to ensure the safety of residents at risk for falls for one of 24 residents reviewed (Resident I7). Findings include: Review of Resident I7's quarterly assessment, dated December 13, 2016, revealed that the resident had moderate cognitive impairment and that the resident was an extensive assist of one for transfer, ambulation and toileting. Further review revealed [DIAGNOSES REDACTED]. Review of Resident I7's active care plan revealed that the resident was at risk for falls related to unsteady gait, self determination (non-compliance with using call bell) for transfers and history of falls. Further review indicated interventions to include remind resident to call for assistance when using the toilet and frequent checks when the resident was in his room. Review of facility documentation of the resident's fall on December 21, 2016 revealed that the resident was found on the floor of his bathroom with a scant amount of blood around his nose. Review of the statement signed by the nursing assistant assigned to the resident's care on that date, revealed that he took the resident to the bathroom at 6:10 p.m., then went to assist another resident to the bathroom and put that resident to bed, then went to deliver the residents' mail, returned to the bathroom and found Resident I7 on the floor of the bathroom at 7:15 p.m. Interview with the unit manager, licensed staff Employee E3, on December 28, 2016 at 12:00 p.m. confirmed that this was a long time to leave a resident on the toilet unattended. The unit manager further stated that there was no documented evidence that the nursing assistant was educated about leaving a resident on the toilet for such a long period of time. The facility failed to provide adequate supervision to ensure the safety of a resident at risk for falls. 28 PA Code 201.14(a) Responsibility of licensee 28 PA Code 201.18(b)(1) Management Previously cited 12/4/2016; 11/9/2015 28 PA Code 211.10(c)(d) Resident care policies 28 PA Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/9/2015

Based on clinical record review, review of select facility policies, and interviews with staff, it was determined that the facility failed to provide effective safety measures, including staff supervision, to prevent a fall resulting in injury for one of 21 residents reviewed (Resident R15). Findings included: Review of the facility's "Resident Accident/Incident Reporting Policy" updated September 15, 2011, revealed that the purpose of the policy is to provide a safe, secure environment for their residents. The Nurse Aide Assignment Sheet (a list of assignments and treatment measures designed for residents based on their needs from their plan of care) prepared for Resident R15, based on her plan of care and assessments, revealed that she must have two Nurse Aides with her during her shower. Resident R15's plan of care also revealed that Resident R15 was to have "appropriate staff to ensure a safe environment." Review of the Minimum Data Set quarterly assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 22, 2011, identified that Resident R15 was cognitively intact with a 15 of 15 BIMs (Brief Interview Mental) score. Her assessment revealed that she required the extensive assistance of two people with transfers. The clinical record indicated that Resident R15 also had [DIAGNOSES REDACTED]. Resident R15's care plan for potential for falls dated February 8, 2011, indicated that she required extensive assist with transfers. The nurse's progress note dated November 30, 2011, at 7:40 p.m., reported that Resident R15 fell when Nurse Aide (NA 3) transferred her up a ramp seated in a shower chair. Resident R15 fell backward hitting the back of her head and left shoulder and she sustained a closed head injury. The Registered Nurse assessment at the time of the fall revealed that initially Resident R15 did not complain of pain. She was assisted up to a seated position and transferred to her room. At that time, she complained of pain in her left shoulder and the lower back of her head. The facility called the physician, and he ordered Resident R15 to be sent to the hospital for evaluation in the Emergency Department. Resident R15 returned to the facility five hours later. The assessment from the hospital revealed [DIAGNOSES REDACTED]." Nursing documentation dated December 3, 2011, at 2:30 p.m. indicated that Resident R15 presented with increased head pain. At 3:10 p.m., Resident R15 was still complaining of head pain (10 out of 10), "oriented, but lethargic," and complained of nausea. The physician was contacted and ordered the facility to send Resident R15 back to the hospital. Resident R15 returned to the facility at 9:00 p.m. on the same day. The assessment from the hospital revealed [DIAGNOSES REDACTED]. The CT Scan (Computed Tomography, used to get a very detailed image of the brain) was negative (no bleeding or swelling). At 10:50 p.m. on December 3, 2011, the facility notified the physician regarding her return and [DIAGNOSES REDACTED]." The Physician ordered a bone scan to be done on Monday (December 5, 2011) of the Cervical Spine. Nursing documentation dated December 4, 2011, at 2:30 a.m., revealed that Resident R15 was difficult to arouse. Nursing documentation at 12:00 p.m., revealed that Resident R15 remained lethargic, did not respond appropriately to questions, and was disoriented. The facility called the Physician with regard to her status report and did not issue any new orders. At 3:45 p.m., on December 4, 2011, nursing documentation indicated that Resident R15 remains lethargic, barely recognizes her daughter, disoriented, and is still not responding appropriately to questions. The physician was notified and orders were received to discontinue Aspirin and arrange for a neurology consult for December 5, or December 6, 2011. At 7:55 p.m., nursing documentation indicated that Resident R15 has had a significant change since the start of the shift. She is disoriented, lethargic, does not recognize family or staff, does not respond appropriately to questions, speech slurred, cannot follow commands, and severe twitching in her right leg. Resident R15 also complained of not being able to see. The physician ordered the facility to send Resident R15 back to the hospital on December 4, 2011, at 10:55 p.m. The hospital admission record dated December 5, 2011, at 1:55 a.m. indicated that Resident R15 was diagnosed with [REDACTED].e. a fall resulting in a closed head injury). Interview with the Director of Nursing (DON) on December 8, 2011, at 11:00 a.m., revealed that NA 3 did not follow the policy and procedure for accident prevention. NA 3 did not follow Resident R15's plan of care or the Nurse Aide Assignment Sheet. The DON indicated that NA 3 should have used a two person assist with Resident R15. Interview with the Nursing Home Administrator on December 8, 2011, at 2:30 p.m., confirmed that NA 3 should have followed the policy and procedure and used a two person assist with Resident R15's transfer. 28 Pa. Code 201.14 (a) Responsibility of licensee. Previously Cited 11/05/2010 28 Pa. Code 211.10 (d) Resident care policies. Previously Cited 11/05/2010 and 02/28/2011 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously Cited 11/05/2010 and 02/28/2011