Every finding on record at Preston Residence

Based upon clinical record review, it was determined that the facility failed to ensure Minimum Data Set Assessments (MDS) were completed accurately for one of 12 residents reviewed (Resident 2).Findings include:Review of Resident 2's Quarterly Minimum Data Set (periodic assessment of resident needs) dated May 13, 2026, revealed Resident 2 to have had a significant weight loss.Review of Resident 2's Weight Summaries from October 1, 2025, through July 1, 2026, failed to reveal evidence of a significant weight loss.Interview with Licensed Employee E3 on July 30, 2026, at 12:27 p.m. revealed that Resident 2's Quarterly MDS dated [DATE], was completed inaccurately and further that Resident 2 did not have a significant weight loss. 28 Pa. Code 211.5 Medical Records

Based on clinical record review and interview with staff, it was determined that the facility failed to encode a subset of items upon a resident's reentry to the facility for one of 12 residents reviewed (Resident 34). Findings include:Review of Resident 34's discharge MDS (Minimum Data Set - periodic assessment of resident needs) of May 27, 2024, indicated that the resident was discharged with return anticipated. Review of Resident 34's late entry progress note of June 7, 2026, revealed that resident returned to the facility on June 6, 2026. Further review of the clinical record revealed no evidence that a reentry assessment was completed. Interview with Employee E3 on July 30, 2026, at 11:52 a.m. confirmed that a reentry assessment had not been completed.

Based upon clinical record review, it was determined that the facility failed to ensure Minimum Data Set Assessments (MDS) were completed timely for three of 12 residents reviewed (Resident 23, Resident 33 and Resident 34).Findings include: Review of Resident 23's clinical record revealed Resident 23 was admitted to the facility on [DATE]. An admission Minimum Data Set Assessment (MDS -periodic assessment of resident needs) was completed upon admission on [DATE]. Further review of Resident 23's clinical record failed to reveal evidence that any further MDS were completed since March 13, 2026. Interview with Licensed Employee E3 on July 30, 2026, at 11:52 a.m. confirmed that no further MDS was completed for Resident 23 since admission on [DATE]. Review of Resident 33's clinical record revealed that the resident was admitted on [DATE], and an admission MDS was completed on January 27, 2026. Further review of the clinical record revealed that no further MDS assessment was completed since admission. Review of Resident 34's clinical record revealed that a quarterly MDS assessment was completed on March 10, 2026. Further review of the clinical record failed to reveal evidence that any further MDS were completed since March 10, 2026. Interview with Licensed Employee E3 on July 30, 2026, at 11:52 a.m. confirmed that the quarterly assessments were not completed for Resident 33 and Resident 34.

Based upon clinical record review and interview, it was determined the facility failed to ensure non-pharmaceutical interventions were completed prior to the administration of pain medication for one resident and failed to ensure side effects were being monitored during the use of anti-psychotic medication for one resident (Resident 4 and Resident 11). Findings include: Review of Resident 4's physician orders revealed an order for Oxycodone (pain medication) 10 milligrams (mg) to be administered every eight hours as needed for moderate to severe pain. Review of Resident 4's June Medication Administration Record revealed Resident 4 received Oxycodone 10 mg on June 1, 2025, June 2, 2025, June 3, 2025, June 6, 2025, and June 10, 2025. Further review of Resident 4's clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of Oxycodone 10 mg. Interview with the Director of Nursing on June 12, 2025, at 1:00 p.m. confirmed that non-pharmaceutical interventions were not attempted prior to the administration of Resident 4's pain medication. Review of Resident 11's diagnosis list revealed a diagnosis of Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions), unspecified mood disorders and anxiety disorder. Review of Resident 11' s physician's orders revealed an order started on Decemebr 5, 2024 for Quetiapine (anti-psychotic medication) 25 milligrams 1 tablet at bedtime. Review of Resident 11's Medication Administration Record (MAR) for May 2025 and June 2025 revealed Resident 11 received Quetiapine 25 milligrams each day at bedtime. Review of Resident 11's MAR and progress notes revealed the facility failed to ensure that side effects were being monitored during the use of anti-psychotic medication. Interview with the Director of Nursing on June 13, 2025, at 9:18 a.m. confirmed there was no documentation monitoring the side effects of the anti-psychotic medication when administered to Resident 11. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 7/11/2024

Based on review of clinical records and staff interviews, it was determined the facility failed to ensure that fluid restriction physician's orders were followed for one of one residents reviewed. (Resident 10) Findings include: A review of the facility's policy titled Diets and Menus, Subject: Fluid Restrictions revised 5/2023 revealed Nursing will document fluid restrictions, intake and output as per nursing policy and procedures or as per physician orders. Review of Resident 10's clinical record revealed diagnoses including acute congestive heart failure(sudden and severe condition where the heart can't pump enough blood to meet the body's needs, causing fluid buildup in the lungs and other parts of the body), and acute kidney failure (a sudden and significant loss of kidney function). Review of Resident 10's physician's orders revealed an order started on May 26, 2025, of fluid restriction of 2000cc, Split between Nursing (1000cc) and Dining (1000cc) daily. 7-3:450cc, 3-11:450cc,11-7:100cc. Review of Resident 10's Medication Administration Record revealed Resident 10's daily fluid allotment was not recorded from June 1, 2025, to June 10 2025. Interview with Director of Nursing on June 12, 2025, at approximately 12:24pm confirmed that the physician orders were not followed for fluid restriction. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review and staff interview, it was determined the facility failed to ensure accurate Minimum Data Set Assessments were completed for one of 12 residents reviewed (Resident 14). Findings include: Review of Resident 14's clinical record revealed diagnoses including End Stage Renal Disease (failure of kidney function to remove toxins from the blood). Review of Resident 14's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated Mach 17, 2025 failed to reveal Resident 14's diagnosis of End Stage Renal Disease. Interview with Licensed Employee E3 on June 12, 2025, at 11:43 a.m. confirmed Resident 14's Quarterly MDS dated [DATE], was inaccurately completed. 28 Pa. Code 211.5(f) Clinical Records

Based on observations and resident and staff interview, it was determined the facility failed to ensure Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for two of 19 residents (Residents 69 and 120). Findings include: Interview with Resident 69 on July 9, 2024, at 11:10 a.m. revealed the resident had a suprapubic catheter (tube that drains urine through the bladder via an incision in the abdomen). Observation of Resident 120 on July 9, 2024, at 10:50 a.m. revealed the resident had a central line (catheter that goes into a vein that leads to the heart) and a left knee surgical wound. Observations of Resident 69 and 120's rooms on all four days of the survey failed to reveal personal protective equipment located outside the rooms or signage indicating that the residents were on Enhanced Barrier Precautions. Interview with the Director of Nursing on July 11, 2024, at 10:50 a.m. confirmed that Residents 69 and 120 were not on Enhanced Barrier Precautions. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on clinical record review and interviews with staff it was determined that the facility failed to ensure assessments accurately reflect the resident's status for one of 17 residents reviewed (Resident R3). Findings include: Review of Resident R3's clinical record revealed a nursing note dated May 16, 2023, indicating the resident was discharged to another facility. Further review of the clinical record revealed a discharge Minimum Data Set (MDS-periodic assessment of the residents care needs) was not completed. Interview conducted with licensed Employee E4 on August 30, 2023 at 10:55 a.m. revealed the discharge MDS assessment was not completed. The facility failed to ensure assesments accurately reflect the resident status for Resident R3. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to treat resident with dignity and respect during the lunch meal for three out of 6 residents ( R8, R9, and R13). Finding include: Review of facility policy labeled Feeding Policy, dated January 2023, outlined the procedure for feeding a resident stating, 20. If the resident must be fed, make yourself comfortable. Sit infront of the resident . Maintain eye contact. Observations on August 28, 2023, at 12:10 p.m. revealed registered employee E3, standing at a back table with residents R8, R9, and R10 seated around the end of the table. Registered Nurse, Employee E3 stood in between residents R9 and R13, feeding a small bite to R9 and then to R13, moved the chair out of the way and fed R8, conducted while in a standing position. This continued throughout the meal moving from one resident to the next without sitting down. Observations on August 29, 2023, at 12:10 p.m. revealed Registered Nurse, Employee E3, standing at a back table while feeding the residents in the same manner as observed on August 28, 2023. Interviews with the Nursing Home Administrator and the Director of Nursing on August 30, 2023 at 11:15 a.m. confirmed that the staff should sit to feed the residents. The facility failed to treat the residents with dignity and respect during the lunch meal for residents R8, R9, and R13. 28 Pa Code: 201.29(j) Resident's rights

Based upon clinical record review, it was determined that the facility failed to ensure the physician provided clinical rationales for declining consultant pharmacist recommendations for 3 of five sampled residents reviewed (Resident 6, Resident 7, and Resident 8). Findings include: Review of Resident 6's Consultant Pharmacist Recommendation dated February 11, 2022 revealed a recommendation to reduce Resident 6's antidepressant medications from two medications to one medication. Review of Resident 6's physician response to the Consultant Pharmacist Recommendation was to continue current treatment and failed to provide a clinical rationale to do so. Review of Resident 7's Consultant Pharmacist Recommendation dated May 5, 2022 revealed a recommendation to reduce the number of antidepressants Resident 7 was being administered from two to one. Review of Resident 7's physician response to the Consultant Pharmacist Recommendation was to continue treatment and failed to provide a clinical rationale to do so. Review of Resident 8's Consultant Pharmacist Recommendations dated March 7, 2022, June 7, 2022 and September 2, 2022 revealed recommendations to reevaluate the use of [MEDICATION(S)] PRN (as needed). Review of Resident 8's physician responses to the Consultant Pharmacist Recommendations were no changes, continue as is and keep as is and failed to provide clinical rationales for those recommendations. Interview with the Director of Nursing on October 18, 2022 at 11:30 a.m. confirmed the above findings. The facility failed to ensure that a clinical rationale was provided by the physician to the Consultant Pharmacist Recommendations. 28 Pa. Code 201.18(b)(1)(2) Management Previously cited 9/15/2021

Based on clinical record review and interview with staff, it was determined that advanced directives did not correspond with the resident's chart for one of 16 residents reviewed. (Resident 72) Findings include: Review of Resident 72's clinical record revealed an admitted [DATE]. The quick reference banner on the electronic record revealed that the resident was a DNR (Do Not Resuscitate). Further review of the clinical record revealed a physicians note dated October 12, 2022, that the nurse practitioner discussed their POLST (an advance directive/ living will) and wishes to be a full code. Review of the the clinical record under physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 72's clinical record revealed a POLST form signed by the resident indicating that cardio-pulmonary resuscitation on October 12, 2022. An interview was conducted on October 18, 2022, at 10:00 a.m. with the Director of Nursing that the banner on Resident 72's clinical record was incorrect. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy services provided medications timely for one of 16 residents reviewed. (Resident 69) Findings include: Review of Resident 69's clinical record revealed the resident was admitted to the facility on [DATE] and has a diagnosis of essential Hypertension (high blood pressure that doesn't have a known secondary cause). Review of Resident 69's physician's orders revealed the resident had an order for [MEDICATION(S)]-[MEDICATION(S)] (HCTZ) tablet (medication used to treat high blood pressure) one time a day. Review of Resident 69's progress notes revealed a physicians note dated October 9, 2022, stating that the resident blood pressure is increased likely due to the blood pressure medication not delivered from the pharmacy, [MEDICATION(S)]-HCTZ. Further review of Resident 69's clinical record revealed the October 2022 Medication Administration Record stated that the resident received the medication on October 2nd through the 5th, however on October 6, 2022, the record indicates, medication is out of stock. On October 7, 2022 the record indicates, medication on order. On October 8, 2022 the record indicates, drug unavailable', and on October 9, 2022 the record indicated, called pharmacy again. Medication was available on October 10, 2022. The above information was discussed and confirmed with the Nursing Home Administrator and Director of Nursing on October 18, 2022, at 2:30 p.m. 28 Pa. Code: 211.10 (c) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based upon clinical record review, it was determined that the facility failed to ensure residents were free from accidents and hazards for one of 16 sampled residents (Resident 8). Findings include: Review of Resident 8's diagnosis list revealed diagnoses including major Depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine). Review of Resident 8's clinical progress notes dated July 5, 2022 revealed Resident was found with several pink oblong pills in bed and on floor under bed. Found to be Benadryl pills. DON made aware and PA [physician assistant] also made aware. This shift, resident was made aware and spoken to by PA. Resident in therapy and had slurred speech and was not herself. PA was notified and seen resident. VSS [vital signs stable]. Will monitor neuro checks and VS [vital signs] if worse will send out. Resident admitted that she felt very depressed but has not talked to anyone about this. Further review of Resident 8's clinical progress notes dated July 6, 2022 from PA [Physician Assistant] revealed Patient seen and evaluated when notified that pt [patient] was having slurred speech. Upon eval pt with cognitive delay and slow speech. No facial drooping or extremity weakness. Does admit to taking Benadryl today due to her tongue feeling swollen, no abnormalities noted on exam. Pt denies any dizziness, N/V [nausea, vomiting], SOB [shortness of breath], issues swallowing or trouble eating today. She says she just feels very tired. She is alert x 4 at time of visit. Discussed with pt that current status may be due to med interaction or side effect or may be due to unrelated acute pathology that we may not know about such as [CONDITION(S)] [[CONDITION(S)] - stroke], TIA [transient eschemic attack - similar to stroke], bleed, etc. Recs [recommendations] to send pt to hospital but pt adamantly refused saying 'even if I'm having a stroke, they'll just send me back here, educated patient that depending on the findings the hospital providers will treat accordingly, but pt still refused. Advised pt that we would like to notify her daughter of the situation but again she refused. She said she would call her later to notify her. Further clinical record review failed to reveal evidence that an investigation was conducted to determine how Resident 8 obtained Benadryl and failed to reveal evidence that the facility conducted an investigation to determine if Resident 8 had more medication. Interview with the Director of Nursing on October 18, 2022 at 11:00 a.m. confirmed that no investigation was completed or conducted to determine the origin of the Benadryl or to determine if Resident 8 had more medication in her possession. The facility failed to ensure Resident 8 was free of accidents and hazards. 28 Pa. Code 201.18(b)(1)(2) Management Previously cited 9/15/2021

Based on clinical record review and interviews with the staff it was determined that the facility failed to ensure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident 72's clinical record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed an physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed on October 12, 2022, the weight was documented as 212.4 pounds and October 13, 2022, the weight was 214.6 pounds, an increase of 2.2 pounds. There is no further documentation that the phsycian was notified of the weight gain. An interview with the director of nursing on October 18, 2022, at 1:25 p.m. that confirmed that the physician was not notified. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review it was determined that the facility failed ensure that an accurate Minimum Data Set (MDS) assessment was completed for one of one sampled resident reviewed (Resident 6). Findings include: Review of Resident 6's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated August 2, 2022 revealed Resident 6 was administered anticoagulants. Review of July and August 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Medication Administration Records (MAR) dated July, 2022, and August, 2022 failed to reveal evidence that Resident 6 was administered anticoagulants. Interview on October 18, 2022 at 11:35 a.m. with Employee E4 confirmed that the MDS was inaccurately completed and confirmed that Resident 6 was not receiving anticoagulants. The facility failed to ensure that MDS assessments were completed accurately. 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/15/2021, 12/14/2021

Based on review of clinical records and interviews with staff it was determined that the facility failed to ensure that a comprehensive, accurate, standardized assessment of the Minimal Data Set within 14 for for three out of three residents reviewed (Resident 69, 70 and 73). Findings include: Review of the Resident 69's clinical record revealed an admitted [DATE]. Further review of the clinical record on Ocotber 18, revealed that the comprehensive Minimal Data Set for admission was not completed. Review of the Resident 70's clinical record revealed an admitted [DATE]. Further review of the clinical record on Ocotber 18, revealed that the comprehensive Minimal Data Set for admission was not completed. Review of the Resident 73's clinical record revealed an admitted [DATE]. Further review of the clinical record on Ocotber 18, revealed that the comprehensive Minimal Data Set for admission was not completed. An interview was conducted with the NHA on October 18, 2022, at 1:00 p.m. revealed that they were not completed due to staff being on vacation. 28 Pa Code 201.18(e) Management 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/14/2021, 9/15/2021

Based on review of select facility policies and procedures, closed financial record review, and staff interview, it was determined that the facility failed to ensure the understanding of required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for one of three records reviewed (Residents 5). Findings include: Review of the form title Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs. Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months, revealed that Resident 5 did not have the form NOMC CMS- given to them. Interview with Nursing Home Administrator on October 18, 2022, at 1:30 p.m. confirmed that the facility could not find documented evidence that Resident 5 or their representatives received or signed the advanced beneficiary notice. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights FACILITY Beneficiary Protection Notification 10/18/22 12:31 PM [NAME] [NAME] ABN was not given to Gates

Based upon review of facility policy and procedure and clinical record review it was determined the facility failed to ensure the physician was notified of significant weight gain and significant weight loss for two of 16 sampled residents reviewed (Resident 6 and Resident 9). Findings include: Review of facility policy and procedure titled Resident Weighing Policy, revised December 2016, revealed Residents who are noted to have a 5 pound weight gain or loss will automatically have a reweight ASAP in the next 24 hours. Reweights that continue to show a 5 pound weight gain or loss must be reported immediately to supervisor. Further review of the policy revealed When a significant weight change (gain or loss) occurs: Charge Nurse will notify physician and dietitian. Weekly weights x 4, appropriate nutrition interventions will be initiated. Review of Resident 6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 6's Weight Summary revealed Resident 6's weight on August 17, 2022 was 200.8 pounds. Further review of Resident 6's Weight Summary revealed Resident 6's weight on September 7, 2022 was 236.2 pounds indicating a 35.4 pound weight gain in three weeks. Review of Resident 6's clinical record failed to reveal evidence that a reweight was obtained and failed to reveal evidence that Resident 6's physician was notified of the significant weight gain as stated in the facility policy and procedure. Review of Resident 9's Weight Summary revealed on August 2, 2022 Resident 9 weighed 162.4 pounds. Further review of Resident 9's Weight Summary revealed on August 17, 2022 Resident 9 weighed 150.8 pounds indicating an 11.6 pound weight loss (7.14%) in two weeks. Review of Resident 9's clinical record failed to reveal evidence that a reweight was obtained and failed to reveal evidence that Resident 9's physician was notified of the significant weight loss as stated in the facility policy and procedure. Interview with the Director of Nursing on October 18, 2022 at 11:00 a.m. confirmed that no reweights were obtained for Resident 6 and Resident 9 and the physician was not notified of Resident 6's significant weight gain and not notified of Resident 9's significant weight loss. The facility failed to ensure reweights were obtained and failed to notify the physician regarding Resident 6 and Resident 9's significant weight gain and significant weight loss. 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/14/2021, 9/15/2021 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 12/14/2021, 9/15/2021

Based on observation, it was determined that the facility failed to provide nursing care which maintained residents dignity for two residents out of 24 in the facility (Resident 13 and 75). Findings include: Observation conducted on October 16, 2022, at 9:30 a.m., revealed Resident 75 sitting in the lobby on a recliner dressed in a gown and his catheter bag on the floor. Further observation of Resident 75 on October 17, 2022, at 11:30 a.m. revealed the resident sitting in a wheelchair at an activity dressed in a sweatshirt with a gown over it. The resident was not wearing pants and red socks were visible. At 12:00 p.m. Resident 75 was seen in the dining room with the same amount of clothing. Further observations on October 17, 2022, at 12:00 p.m. revealed Resident 13 being taken to lunch. An outside lab phlebotomist approached the resident in the hallway and stated she need some blood work. The Nurse Aide Employee E3. stated that the blood work can be done in the hallway, right outside of the dining room. The blood draw was performed a few minutes later in the hallway. The findings were reported to the Administrator and the Director of Nursing on October 18, 2022, at 10:51 a.m. and confirmed that Resident 75 and Resident 13 were not treated with dignity in these instances. 28 Pa Code 201.14(a) Responsibility of licensed 28 Pa Code 201.18(b)(1) Management

Based on review of facility policy, review of clinical records, review of facility documentation, and interviews with staff, it was determined that the facility failed to ensure that thorough assessments were completed after a fall for two of three residents reviewed (Residents R1 and R2). Findings include: Review of facility policy, Fall Prevention/Investigation Protocol, revised January 2020 revealed that if suspected head trauma and/or unwitnessed fall, the nurse initiates neuro checks [neurological examination - assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired]. Review of neurological assessment form revealed that assessments are to be completed every 15 minutes for four times, then every 30 minutes for four times, then every 60 minutes for four times, and then every 8 hours for four times. Review of Resident R1's progress note of October 29, 2021, revealed resident was alert with confusion. Review of Resident R1's progress note of November 2, 2021, revealed that at 2:20 p.m. the resident was heard calling for help and was found lying on the floor in the bathroom in front of the toilet. Resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Vital signs were taken. Review of facility documentation revealed that an initial assessment including neuro checks was completed. Review of progress note of November 2, 2021, revealed that resident's family requested resident be sent to the hospital and resident left the facility at approximately 8:00 p.m. Further review of the clinical record and facility documentation revealed no further assessment or neuro checks were completed between the time of the fall and the time the resident was sent to the hospital. Review of Resident R2's progress note of October 26, 2021, revealed resident was admitted after having multiple falls at home. Review of progress note of December 11, 2021, revealed resident was found on his/her knees, holding on to the walker. Review of facility documentation revealed that an initial assessment including neuro checks was completed. Further review of the clinical record and facility documentation revealed no further assessment of the resident. Interview with the acting Director of Nursing on December 14, 2021, at 1:35 p.m. revealed that all residents with unwitnessed falls are to have neuro checks completed and would have expected them to be completed for Resident R1. Interview with the Nursing Home Administrator and acting Director of Nursing on December 14, 2021, at 2:10 p.m. confirmed that neuro checks were not completed for Resident R2. 483.25 Quality of Care Previously cited 9/15/21 28 Pa. Code: 211.5(f) Clinical records Previously cited 9/15/21 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 9/15/21

Based on a review of closed clinical records and staff interviews, it was determined that the facility failed to monitor and complete ongoing assessments after a change in condition, shortness of breath, for one of two residents reviewed (Resident CL1), which resulted in Resident CL1's transfer to the hospital, and admission to the intensive care unit with a [DIAGNOSES REDACTED]. Findings include: Review of Resident CL1's closed clinical record revealed that the resident was admitted to the facility on (MONTH) 2, (YEAR) with a [DIAGNOSES REDACTED]. Review of Resident CL1's hospital discharge summary dated (MONTH) 2, (YEAR), revealed the resident was admitted to the hospital on (MONTH) 30, (YEAR), for elective surgery of a right total hip arthroplasty. Further review of the hospital discharge summary dated (MONTH) 2, (YEAR) obtained by the facility at the time of admission revealed that the physician was to be notified if the resident experienced shortness of breath, pain in the incision, chest pain, and symptoms worsened. Review of Resident CL1's physician's orders [REDACTED]. A review of Resident CL1's closed record revealed a nursing progress note dated (MONTH) 13, (YEAR), at 1:50 a.m. identified as a late entry note from the 3-11 shift indicating that the Resident c/o SOB (complaining of shortness of breath) at 1600 (4:00 p.m.), on assessment b/l (bilateral) lungs clear, negative for cough, denies pain with deep inspiration, Sp02 (peripheral capillary oxygen saturation) at 95% RA (room air, normal 95%-100%), RR (respiratory rate; normal 12-18 breath per minute) 22, denies increase/decrease in SOB since onset at approximately 1400 (2:00 p.m.). Nurse questioned resident about anxiety r/t (related to) upcoming discharge, resident stated, it's all that's on my mind. Resident questioned possibility of blood clot per conversation with a friend. Nurse informed the resident that a blood clot may show pain with inspiration, worsening SOB, a low pulse ox (pulse oximetry - measures your oxygen saturation level). Resident denied all symptoms listed. Nurse monitored resident throughout shift, continued with SOBOE (shortness of breath on exertion), at times with conversation, continued to deny pain. Nurse offered to notify MD r/t SOB, resident declined offer, stated that if by next morning SOB did not resolve, she would f/u (follow-up) with the nursing staff. At HS (hours of sleep), resident negative for SOB, lying comfortably in bed. Oncoming shift aware. Further review of Resident CL1's nursing documentation revealed that there was no documented evidence of the continued monitoring and assessment of Resident CL1's change in condition throughout the 3-11 shift on (MONTH) 12, (YEAR), and 11-7 shift on (MONTH) 13, (YEAR). There was no documented evidence that the staff observed for signs and symptoms of shortness of breath, chest pain, lightheadedness, pain in lower extremities, dry cough and vital signs (low oxygen level, increased heart rate, increased respiration or palpitations) after Resident CL1 complained of shortness of breath on (MONTH) 12, (YEAR), onset at approximately 2:00 p.m. The next available nursing documentation was dated (MONTH) 13, (YEAR), at 10:54 a.m. by Registered Nurse, Employee E4. The documentation revealed the Pt. still c/o SOB, pulse ox was down to 84% RA: O2 was applied. Pt. denied any pain when she took a deep breathe. No pain in legs. Physician came in, saw pt (patient) ordered stat (immediate) CXR (chest x-ray) to R/O [MEDICAL CONDITION] (rule out [MEDICAL CONDITION]) .X-ray ordered. VS (vital signs) monitored: B/P (blood pressure) down and HR (heart rate) not as rapid as this am, Pulse Ox only 91% with 2L (2 liters) of O2 (oxygen) increased to 3L n/c (3 liters using a nasal cannula). Pt is anxious about being SOB. Reassurance is given. Review of Resident CL1's nursing progress note dated (MONTH) 13, (YEAR), at 1:04 p.m. indicated the resident wanted to go to the hospital regarding not waiting for the X-ray. Pt stated that she spoke with her daughter and daughter said she may have a Bld (blood) clot and should go to the ER (emergency room ). Called NP (nurse practitioner) and spoke with her, Pt BP is elevated and HR 125 (normal heart rate is 60-100 in women) Pulse ox 90% with 3/L (liters) of O2. Orders given to send pt to ER . Ambulance was called and pt was being transferred to hospital emergency room . Review of Resident CL1's nursing progress note dated (MONTH) 13, (YEAR), at 15:07 p.m. revealed nurse spoke with hospital emergency room and they stated resident is being admitted with PE's (pulmonary embolism - a condition in which one or more arteries in the lungs become blocked by a blood clot). Review of Resident CL1's hospital records dated (MONTH) 13, (YEAR), at 3:33 p.m. confirmed patient was found to have bilateral [MEDICAL CONDITIONS] following a right total hip arthroplasty two weeks ago and was admitted to the Intensive Care Unit. Interview with the Director of Nursing on (MONTH) 27, (YEAR), at approximately 3:00 p.m. confirmed there was no documented evidence of the continued monitoring and assessment of Resident CL1's change of condition throughout the 3-11 shift on (MONTH) 12, (YEAR), and 11-7 shift on (MONTH) 13, (YEAR). The facility failed to continuously monitor and assess Resident CL1 after the onset of symptoms of shortness of breath and anxiety from (MONTH) 11, (YEAR), at 11:10 a.m. until the resident was emergently transferred to the emergency roiagnom on (MONTH) 13, (YEAR) at 1:04 p.m. and admitted to the intensive care unit with a [DIAGNOSES REDACTED]. Quality of Care CFR(s): 483.25 - Previously cited 12/15/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/03/17, 12/15/16 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 11/03/17, 12/15/16 28 Pa. Code 201.18(b)(3) Management Previously cited 12/15/16 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/03/17, 12/15/16 28 Pa. Code 211.12(d)(2)(3) Nursing services