Every finding on record at Quakertown Center

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of two nursing units. (North unit)Findings include:Review of the facility policy entitled, Food Storage: Cold Foods, dated December 18, 2025, revealed that staff were to label food items with the date prepared or opened. Observations during the kitchen tour on March 15, 2026, at 9:30 a.m., revealed the following:There was a thick layer of dust and debris on top of the dish machine. In the walk-in cooler, there were two boxes of cooked diced chicken on top of milk crates with milk stored in them. The bottom box of chicken, that was in contact with the milk crates, had a red stain on it. There was a box of raw chicken fillets touching the floor. On a shelf, there was an opened butter package with a brown substance on the bottom, and both were in contact with the shelf. There was a container of sweet and sour sauce labelled with a use by date of March 10, 2026. There were two large containers of sour cream labelled with a use by date of February 16, 2026. In the walk-in freezer, there was an opened half gallon of ice cream that was not dated. In dry storage, there was a box of bananas and a large bag of onions stored on the floor. There was a box of cranberry juice that was dated use by March 6, 2026. There was a box of prune juice that had food debris on it. There was food debris and several condiment packets on the floor. There was a box of chocolate chips that was not sealed. In the reach-in cooler, there were three shelled eggs in a pan, three poured glasses of orange juice, and two glasses of tea that were not dated. There was an opened bag of whipped topping that was dated use by March 5, 2026. In an interview on March 15, 2026, at 3:25 p.m., the Dietary Director confirmed that the previously mentioned food items should have been dated and the expired items removed. Review of the facility policy entitled, Food Brought in for Residents, dated December 18, 2025, revealed that foods that required refrigeration were to be labelled with the resident's name and date. Observation of the North unit resident pantry on March 15, 2026, at 12:11 p.m., revealed a piece of brownie and pie on a plate and a bottle of soda in the freezer that were not labelled with a name or dated. In the refrigerator, there was a container of yogurt with a hole in the top that was dated use by February 9, 2026. There was a plastic bag with a container of food, an orange, and milk, and a container of two slices of cheesecake that were not labelled or dated. Along the bottom shelf, there was an area of pink, dried, and sticky liquid that had spilled onto the floor in front of the refrigerator. On the counter there was a banana and two pitchers of fruit punch. There were four ants seen crawling on the counter and pitchers. The counter had sticky food debris along the length of it. There were areas of dried food debris inside the microwave. In an interview at that time, Nurse Aide (NA) 1 stated that the microwave and pantry were used for residents only. CFR 483.60(i) Food Safety RequirementPreviously cited 1/10/2628 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on observation and staff interview, it was determined that the facility failed to maintain the resident environment in a sanitary and homelike manner in the main lobby and on one of two nursing units. (North Nursing Unit)Findings include: Observation on March 15, 2026, from 9:45 a.m. to 2:15 p.m., and March 17, 2026, from 9:15 a.m. to 12:45 p.m., revealed the following: Two chairs in the lobby had torn cushions; one with a dark liquid stain on the seat cushion. The lobby wall adjacent to the reception desk had chipped paint and black marks. There were also black marks on the walls across from the reception desk. There were missing floor tiles in front of resident laundry. On the North Nursing unit, the hallway walls between resident rooms [ROOM NUMBERS] were stained with brown streaks under the chair rail molding and there were red stains on the baseboard between resident rooms 101 and103. In resident room [ROOM NUMBER], there was a yellow stain on the floor. In resident room [ROOM NUMBER], the privacy curtain between the beds was stained with brown streaks. The wall under the bathroom sink had holes in the concrete with the rubber baseboard pulling away from the concrete. In resident room [ROOM NUMBER], there was a brown stain on the left side of the bed sheet. There was paper debris and peeling paint behind the bed. Dust and debris was observed on and under the fall mats. The privacy curtain in resident room [ROOM NUMBER] was missing hooks and was marred with light brown stains. In an interview on March 18, 2026, at 2:00 p.m., the Administrator confirmed the identified environmental issues were present. CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike EnvironmentPreviously cited 2/7/25 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(2.1) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 25 sampled residents. (Residents 12 and 14)Findings include:Review of the policy entitled, Medication Administration, General Guidelines, last reviewed December 18, 2025, revealed that staff were to obtain vital signs if necessary, and document necessary medication administration information. Clinical record review revealed that Resident 12 had diagnoses that included hypotension (low blood pressure). A physician's order dated March 1, 2026, directed staff to administer a medication (midodrine) once a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was more than 130 millimeters of mercury (mm/Hg). Review of Resident 12's medication administration record (MAR) for March 2026 revealed that staff administered the medication 16 times with no evidence that the blood pressure was assessed prior to the medication being administered or withheld. Clinical record review revealed that Resident 14 had diagnoses that included diabetes and end stage kidney disease. A physician's order dated December 5, 2025, directed staff to administer 43 units of a diabetic medication (insulin glargine subcutaneous solution) two times a day. Staff were not to administer the medication if the blood sugar was less than 150 milligrams per deciliter (mg/dL). Review of Resident 14's February and March 2026 MARs revealed that the resident was administered the insulin glargine one time in February and one time in March when their blood sugar was less than 150 mg/dL. In an interview on March 18, 2026, at 9:36 a.m., the Director of Nursing confirmed there was no documented evidence the blood pressure was obtained prior to the medication administration for Resident 12 and that the insulin was administered outside of the parameters in the physician's order for Resident 14. CFR 483.25 Quality of CarePreviously cited 1/10/2628 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to post accurate and current nurse staffing information.Findings include:During a tour of the facility conducted on March 15, 2026, 2026, at 9:15 a.m., the staffing information that was posted in the lobby was dated February 20, 2026. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review and resident interview, it was determined that the facility failed to perform a skin treatment as ordered by the physician for one of three sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included a history of an infection of the toes. Since November 4, 2025, the physician ordered that staff clean both great toes and apply an antibacterial ointment (bacitracin). In an interview on January 30, 2026, Resident 1 stated that three days prior on January 27, 2026, the nurse did not perform this treatment. Review of the Treatment Administration Records revealed no documented evidence that nursing staff performed the treatment on January 27, 2026, as ordered by the physician.28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was at an appetizing temperature on one of two nursing units. (North Unit) Findings include: Review of the facility policy entitled, Food Prep, dated December 18, 2025, revealed that hot food served to residents should be greater than 135 degrees Fahrenheit, and cold food items no greater than 41 degrees Fahrenheit (F). In interviews on January 10, 2026, at 11:40 a.m. through 12:00 p.m., Residents 1, 2 and 3 stated that food was often served cold. Results of a test tray audit conducted on January 10, 2026, at 12:33 p.m., after the last resident meal tray was served from the dining cart, revealed the crunchy buttermilk chicken was served at a temperature of 126.5 degrees F and the green beans were served at a temperature of 132 degrees F. Both food items were cool to taste. In an interview during this observation period, the Dietary Manager stated that the hot food should have achieved a temperature of 135 degrees F or higher at the time of service. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on policy review, observation, and staff interview, it was determined that the facility failed to record food temperatures at the time of service in the main kitchen.Findings include: Review of the facility policy entitled, Food Prep, dated December 18, 2025, revealed that food temperature would be recorded at the time of service and monitored periodically during meal service. A review of the facility's food temperature log on January 10, 2026, at 12:15 p.m., revealed that there was no documented evidence that the holding food temperatures were obtained at the time of or during service for breakfast and lunch to ensure that the food maintained safe internal temperatures. In an interview during this observation period, the Dietary Manager stated that the food temperatures should have been recorded for breakfast and lunch at the time of service. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa, Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide the resident and/or the resident's representative with a reconciliation of all pre- and post-discharge medications for one of five sampled residents with a planned discharge. (CL1) Findings include: Clinical record review revealed that CL1 had a planned discharge on [DATE]. There was no documented evidence that the resident and/or the resident's representative was provided a reconciliation of all pre and post discharge medications at the time of discharge. A further review revealed that the representative requested for the reconciliation of medication on August 13, 2025. In an interview on September 4, 2025, at 4:00 p.m., the Administrator confirmed that the resident and/or the resident's representative did not receive the reconciliation of all pre- and post-discharge medications at the time of discharge. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment for residents on two of two nursing units. (South Wing and North Wing) Findings include: Observation from February 4, 2025, between 9:45 a.m. and 1:35 p.m., February 5, 2025, between 8:20 a.m. and 9:00 a.m., and 12:15 p.m. and 2:21 p.m., and February 7, 2025, between 9:10 a.m. and 9:30 a.m. revealed the following: In room [ROOM NUMBER], the walls were heavily marred. In room [ROOM NUMBER], the walls were marred and the closet was missing both doors. In room [ROOM NUMBER], the closet was missing both doors. In room [ROOM NUMBER] bed H, the fan had a heavy accumulation of dust and dirt. In room [ROOM NUMBER]'s bathroom, there was a broken floor tile in front of the toilet and a water-stained ceiling tile. In room [ROOM NUMBER], the walls were heavily marred. In room [ROOM NUMBER], the walls were heavily marred. In the bathroom, there was a large hole in the drywall on the right side of the wall. There was a water-stained ceiling tile. In room [ROOM NUMBER], the windowsill was covered with dirt and debris. The wallpaper was peeling behind bed W. In room [ROOM NUMBER] bed W, the dresser drawer handle was broken. In room [ROOM NUMBER], the ptac unit (ductless air conditioning unit that heats and cools small areas) contained debris and dirt. In the bathroom, the floor was buckled on the left and right sides of the toilet In room [ROOM NUMBER] bed W, there was a solid black thick substance splattered on the floor. In room [ROOM NUMBER]'s bathroom, there was a brown stain along the bottom molding on the wall by the toilet and under the sink. There was a floor tile behind the toilet that was stained with a black substance. In room [ROOM NUMBER], there was an accumulation of dust in the top corner of the window as well as on the curtain. In room [ROOM NUMBER], a layer of floor material in the entry way was lifted away from the base. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 70) Findings include: A review of a facility policy entitled, Dialysis: Hemodialysis- Communication and Documentation, last reviewed October 15, 2024, revealed that staff were to complete the pre-dialysis portion of the Hemodialysis Communication Record that provided information regarding the resident's ongoing status to send with the resident to dialysis. Clinical record review revealed that Resident 70 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis and had a physician's order for the facility to provide dialysis three days per week. There was a lack of evidence to support that the pre-dialysis portion of the resident's dialysis communication forms were completed and that the resident was assessed before dialysis on five of 14 occasions from January 4, 2025, through February 4, 2025. In an interview on February 7, 2025, at 9:35 a.m., the Director of Nursing confirmed that communication forms were to be completed before dialysis to assess residents and that the forms were not completed. 28 Pa. Code 211.12(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 26 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included bipolar disorder and heart failure. On May 17, 2024, the resident weighed 152.4 pounds. On November 1, 2024, the resident weighed 173.6 pounds, which reflected a significant weight gain of 13.9% in the last six months. Review of the physician's orders revealed that Resident 7 had been receiving an antipsychotic medication, olanzapine (a medication that affected brain activities) since May 17, 2024. Review of the November 2024 medication administration record revealed that Resident 7 received olanzapine during the MDS review period. The MDS assessment dated [DATE], incorrectly indicated in section K that Resident 7's weight was 146 pounds, which was not a weight reflected in the resident's clinical record, and that the resident had no significant weight gain in the last six months. Further review of the MDS assessment revealed that section N incorrectly indicated that the resident did not receive an antipsychotic medication in the review period. In an interview on February 7, 2025, at 1:00 p.m., the Director of Nursing confirmed that Resident 7's MDS assessment areas were inaccurate.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 26 sampled residents. (Residents 112, 115) Findings include: Clinical record review revealed that Resident 112 was admitted to the facility on [DATE], and had diagnoses that included chronic kidney failure. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated August 24, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. The quarterly MDS summary dated November 7, 2024, indicated the resident was frequently incontinent of urine. There was no evidence that interventions to address Resident 112's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 115 was admitted to the facility on [DATE], and had diagnoses that included epilepsy (a brain disorder that causes seizures) and rheumatoid arthritis. The MDS CAA summary dated September 14, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. The quarterly MDS summary dated November 27, 2024, indicated that the resident was frequently incontinent of urine. There was no evidence that interventions to address Resident 115's urinary incontinence were included in the current care plan. In an interview on February 7, 2025, at 12:36 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the residents' current care plans. CFR 483.21(b)(1) Comprehensive Care Plans Previously cited 3/8/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one of 26 sampled residents. (Resident 20) Findings include: Review of the facility policy entitled, Pain Management Policy, last reviewed October 15, 2024, revealed that the physician ordered PRN (as needed) pain medications were to have defined parameters for use. Clinical record review revealed that Resident 20 had diagnoses that included chronic venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart), lymphedema (tissue swelling caused by an accumulation of protein-rich fluid drained through the lymphatic system), and Parkinson's disease. There were physician's orders dated November 27, 2024, for the resident to receive the narcotic pain medication tramadol every eight hours as needed for pain (failed to identify pain parameters), ibuprofen every eight hours as needed for pain (failed to identify pain parameters), and acetaminophen every four hours as needed for mild pain. Review of Medication Administration Records revealed that the resident received the as needed narcotic (tramadol) for mild or moderate pain on 35 occasions in December 2024, 23 in January 2025, and six in February 2025. The resident did not receive any doses of the as needed acetaminophen for mild pain or ibuprofen in December 2024, January 2025, or February 2025. In an interview on February 7, 2025, at 12:58 p.m., the Director of Nursing confirmed that parameters had not been ordered for the administration of the prn (as needed) pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure psychotropic medications (medications that affect brain activities) were prescribed for a specific diagnosis for two of seven sampled residents who were prescribed psychotropic medications. (Residents 82, 116) Findings include: Clinical record review revealed that resident 82 had diagnoses that included Alzheimer's disease, anxiety, and stroke. A physician's order dated January 18, 2024, directed staff to administer an antipsychotic medication, Seroquel, at bedtime for agitation. There was a lack of evidence to support that the medication was used to treat a specific diagnosis. Clinical record review revealed that resident 116 had diagnoses that included post traumatic stress disorder (PTSD) and depression. Physician's orders dated January 25, 2025, directed staff to administer antipsychotic medications, haloperidol, every six hours for psychosis and quetiapine, twice daily for psychosis. There was a lack of evidence to support that the medication was used to treat a specific diagnosis. In an interview on February 7, 2025, at 1:11 p.m., the Director of Nursing confirmed that the antipsychotic medication orders should have included specific diagnoses. CFR 483.45(e)(1) Pharmacy Services Previously cited 3/8/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychotropic medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for two of 26 sampled residents. (Residents 43, 67) Findings include: Review of the facility policy entitled, Psychotropic Medication Use, last reviewed October 26, 2023, PRN psychotropic medication should not be ordered for more that 14 days. Residents who were taking PRN psychotropic medications were to have their prescription reviewed by the physician every 14 days. Clinical record review revealed that Resident 43 had diagnoses that included dementia and depression. On February 8, 2024, a physician ordered that staff administer a psychotropic medication (risperidone) every day as needed for anxiety. The order for the risperidone failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. Clinical record review revealed that Resident 67 had diagnoses that included dementia and anxiety. On December 29, 2023, a physician ordered that staff administer a psychotropic medication (lorazepam) every 24 hours as needed for agitation. Review of the Medication Administration Record for March 2024, revealed that staff had administered the prn lorazepam three times and the physician's order was still current. The order for the lorazepam failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on March 8, 2024, at 10:10 a.m., the Director of Nursing confirmed that the there was no evidence the physician documented a rationale for continuing the medications beyond 14 days. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 26 sampled residents. (Resident 119) Findings include: Clinical record review revealed that Resident 119 had a Minimum Data Set assessment completed on February 13, 2024. According to the assessment, the resident received nutrition from a feeding tube. According to the Care Area Assessment summary from that assessment, the facility identified that nutrition and a feeding tube were problem areas for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address these care areas. In an interview on March 8, 2024, at 10:10 a.m., the Director of Nursing confirmed that Resident 119's care plan did not include the areas of potential concern identified in the comprehensive assessment. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and implement safety measures related to smoking for two of two sampled residents. (Resident 6, 83) Findings include: Review of the facility policy entitled, Smoking, last reviewed August 7, 2023, revealed that smoking would be permitted in designated areas, that residents would be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, would be supervised. The policy also required that smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc.) would be labeled with the resident 's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. Clinical record review revealed that Resident 6 had diagnoses that included Post Traumatic Stress Disorder, sacroiliitis, blindness in the left eye, personal history of pulmonary embolism and thrombosis, personal history of hip replacements. According to the Minimum Data Set assessment (MDS), dated [DATE], the resident had no cognitive impairment. Observations on March 5, 2024, at 11:42 a.m., and March 6, 2024, at 10:42 a.m., revealed Resident 6 smoking outside the front of the building. In an interview on March 6, 2024, at 10:42 a.m., Resident 6 reported smoking on a regular basis. There was no documented evidence that the facility completed smoking assessments for Resident 6 after July 8, 2023. Clinical record review revealed that Resident 83 had diagnoses that included Diabetes with polyneuropathy, chronic kidney disease, and paralytic syndrome following a cerebral infarction. According to the MDS, dated [DATE], the resident had no cognitive impairment. In an interview on March 7, 2024, at 12:05 p.m., Resident 83 reported smoking on a regular basis. There was no documented evidence that the facility completed smoking assessments for Resident 83 after October 1, 2023. In an interview on March 7, 2024, at 1:40 p.m., the Director of Nursing and Administrator confirmed that Residents 6 and 83 had been permitted to smoke and that quarterly smoking assessments had not been completed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of seven sampled residents. (Resident 49) Findings include: Clinical record review revealed that Resident 49 had diagnoses that included multiple sclerosis, quadriplegia, and Parkinson's Disease. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for personal hygiene and dressing. Review of the care plan revealed that staff was to apply bilateral hand carrots (orthotic devices) for four hours to prevent contractures and maintain skin integrity. Review of the current physician's orders revealed that staff was to apply bilateral hand carrots four hours daily, on at 10 a.m. and off at 2 p.m. Observation on March 5, 2024, revealed the resident in bed at 11:34 a.m., 12:15 p.m., and 1:10 p.m., without the bilateral hand carrots in place. On March 6, 2024, the resident was in bed at 12:45 p.m., and 1:50 p.m., without the bilateral hand carrots in place. On March 7, 2024, the resident was again in bed at 10:55 a.m. and 1:07 p.m., without the bilateral hand carrots in place. In an interview on March 8, 2024, at 10:45 a.m., the Director of Nursing confirmed that the staff was to apply bilateral hand carrots as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer/discharge and the reasons for the move in writing for eight of 26 sampled residents. (Residents 12, 29, 45, 49, 83, 101, 119, 126) Findings include: Clinical record review revealed that Resident 12 was transferred and admitted to the hospital on September 16, 2023, after a change in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 29 was transferred and admitted to the hospital on January 12, 2024, after a change in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 45 was transferred and admitted to the hospital on December 14, 2023, and December 30, 2023, after changes in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 49 was transferred and admitted to the hospital on December 29, 2023, and February 16, 2024 after changes in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 83 was transferred and admitted to the hospital on July 16, 2023, August 8, 2023, October 4, 2023, and January 19, 2024, after changes in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfers to the hospital. Clinical record review revealed that Resident 101 was transferred and admitted to the hospital on September 30, 2023, after a change in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 119 was transferred and admitted to the hospital on January 25, 2024, after a change in condition. There was no evidence that the resident and resident's representative were provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 126 was discharged from the facility on December 27, 2023, for an increase in behaviors. There was no evidence that the resident and resident's representative were provided with written information regarding the discharge. In an interview on March 8, 2024, at 12:12 p.m., the Administrator confirmed that written transfer or discharge information, including the reasons for the move, were not provided to the residents and residents' representative. 28 Pa. Code 201.29(c.3)(2)

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, family member, or legal representative at the time of transfer for two of 12 sampled residents who were transferred to the hospital. (Residents 45, 101) Findings include: Clinical record review revealed that Resident 45 was transferred and admitted to the hospital on December 14, 2023, and December 30, 2023, after changes in condition. There was no documented evidence that the resident, resident's responsible party, or legal representatives were provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 101 was transferred and admitted to the hospital on September 30, 2023, after a change in condition. There was no documented evidence that the resident, resident's responsible party, or legal representatives were provided written information about the facility's bed-hold policy at the time of transfer. In an interview on March 8, 2024, at 11:20 a.m., the Director of Nursing confirmed that no written notice of the bed-hold policy was given to the resident or residents' representative upon transfer out of the facility.