Every finding on record at Quality Life Services - Sarver

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident R1). This deficiency is cited as past noncompliance.Finding include: Review of facility policy Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation dated 8/12/25, indicated it is the policy of the facility to treat all residents with kindness, respect, and in a manner that is at all times free from any abuse, neglect, misappropriation of property, exploitation or mistreatment. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Review of the facility Bed Mobility Competency checklist indicated employees are to check Kardex (a snapshot of resident care needs) to determine bed mobility. Stand on the side of the bed to which you want to move the resident. If bed mobility is assist of two, one staff member to stand on each side of the bed. If a resident is a bed mobility of two NEVER leave resident alone or perform task/care with assist of one. Review of the facility Nurse Aide Job Description indicated staff are to review care plans and perform nursing care as outlined, assure residents are given adequate assistance with personal and oral hygiene needs following company's policies and procedures and assist residents with activities of daily living as documented in the resident's care plans. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anxiety. Review of a physician order dated 6/5/25, indicated care in pairs at all times each shift for medication and personal hygiene. Review of a physician order dated 5/8/25, indicated low air loss mattress (a specialized support surface used to prevent and treat pressure injuries by continuously circulating a low volume of air), check placement and function QS (every shift). Review of Resident R1's Kardex dated 7/15/26, indicated bed mobility: assist x2 (two staff members), care in pairs, and low air loss mattress. Review of facility submitted documentation dated 7/15/26, indicated the following: At 0700 (7 a.m.) two CNAs (Certified Nurse Aide) went in Resident R1's room to perform ADLs (activities of daily living) with brief change, resident is a care in pairs due to resident's past allegations of abuse in the past and bed mobility assist of 2, requiring 2 people in attendance. AM (morning) care started, then one CNA left room to get supplies and 2nd CNA continued with care, rolling resident onto her left side and resident rolled off bed, landing on the floor. No obvious injury, EMS (emergency medical services) called and took resident to ER (emergency room) for assessment. Review of a staff witness statement, dated 7/15/26, completed by Nurse Aide (NA) Employee E1 stated, Writer went in at 0700 to do AM care on resident while doing care other aide went to get wipes while writer was rolling resident over to the left side then resident rolled out of bed. Nurse walked in while aide was checking on resident, RN (Registered Nurse) was notified. Writer waited with resident, resident was talking and awake until EMS arrived. Review of a staff witness statement, dated 7/15/26, completed by NA Employee E2 stated, I was helping in Resident R1's room to get resident dressed. I went to get wipes and I answered a call light in another resident room. Then people were yelling for me that they needed me in Resident R1's room, and the resident was on the floor. Review of a written verbal statement dated 7/15/26, obtained from NA Employee E1 by Interim Director of Nursing Employee E5 stated, At 0730 (7:30 a.m.) NA Employee E2 and I went into Resident R1's room to do AM care and brief change, NA Employee E2 left to get wipes and I started cleaning her up, rolled resident on to her left side and she rolled off the bed. I didn't know she was a bed mobility of 2 requiring two people to move her in the bed. Review of a staff witness statement dated 7/15/26, completed by Licensed Practical Nurse (LPN) Employee E4 stated, This writer was outside resident's room preparing medications. The aides were doing AM care on resident. Heard a call out for assistance. Upon entering room, resident was on floor in supine position leaning toward right side. Resident was alert and talking. Immediately assessed no open wounds, went to get RN supervisor. Resident remained interactive with staff, expressed being scared, however she was easily reassured. EMS arrived at 0742 (7:42 a.m.) resident left building via ambulance to transport to hospital at 0751 (7:51 a.m.). Review of facility onboarding documentation indicated NA Employee E1 was hired on 10/4/21. During a telephonic interview on 8/12/26, at 11:03 a.m. NA Employee E1 stated, I went in to do morning care with the resident, the air mattress was set a little higher than it should have been, the mattress puffed up and she rolled out of bed. I was not aware that the resident was an assist of two at the time of the incident. I have worked that assignment multiple times before. I work agency for the company, and the company utilizes the same POC (Plan of Care, electronic medical record containing resident care information) throughout all of the facilities. I do know where to look for the POC and I am aware to look at it. The POC tells us how a resident transfers in and out of bed and their bed mobility requirement. I didn't know the resident was a care in pairs until after the situation. Care in pairs means usually two people because something has happened in the past. The direction I roll a resident [away from or towards staff] depends on the resident. Resident R1 has left sided weakness, she can still help with her right hand, she can usually grab the bed rail. During an interview on 8/12/26, at 11:20 a.m. NA Employee E5 stated, To locate resident's bed mobility status, I look in the Kardex in the electronic medical record. We also have binders in every resident hallway with a printout of the Kardex for reference. They are usually kept up to date. I check the Kardex every shift when I come in. We are supposed to have two staff members for residents on an air mattress, so they don't fall off the bed. During care I always roll a resident towards me, I would never roll a resident away from me without having a second person on the other side of the bed. Care in pairs means that we are to have two people in the room at all times. Care in pairs is communicated to the staff in the Kardex and there is also a magnetic tag that is placed outside of the resident rooms to indicate two people are required. During an interview on 8/12/26, at 11:25 a.m. NA Employee E2 stated, To know a resident's bed mobility status, I check the Kardex, it's part of the resident's charting in the electronic medical record, we also have binders in the hallways. Therapy is also pretty good about letting us know if someone's mobility status changes. It is always two staff members with an air mattress. While providing care, I roll the resident towards me, event when it's not an air mattress so I have more control. I would never roll a resident away from myself without a second person on the other side of the bed. Care in pair means two people in the room during care. Most of the time there is a picture outside of the room and it is indicated in the resident's electronic medical record. During an observation on 8/12/26, at 11:35 a.m. a sign was observed outside of Resident R1's room indicating that the resident requires care in pairs. During an interview on 8/12/26, at 11:40 a.m. NA Employee E6 stated, I look in the Kardex to know a resident's mobility status. That should probably be checked every shift before you give care. You have to have two people when you're giving care to a resident on an air mattress. During care I roll the resident towards me when I'm by myself, I would never roll someone away from me when I'm providing care by myself. During an interview on 8/12/26, at 12:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure Resident R1 was free from neglect by failing to provide adequate staff assistance during bed mobility, resulting in a fall from the bed to the floor. This was identified for past noncompliance for Resident R1. On 7/15/26, the facility implemented a plan of correction that included the following:Resident R1 was transferred to the hospital for further assessment.Resident R1's care plan was reviewed and verified bed mobility assistance was documented and accurate.On 7/15/26, all verbal residents were interviewed for abuse or neglect concerns. Non-verbal residents had a skin assessment performed for signs and symptoms of abuse or neglect.On 7/15/26, the DON implemented re-education and competency checklists in all departments on abuse prevention policy.As of 7/29/26, facility was >90% with regard to abuse and neglect education.Beginning 7/29/26, the facility is to perform three skin audits on non-verbal residents, three times a week, for three weeks.The facility's next QAPI (Quality Assurance and Performance Improvement) meeting is scheduled for 8/24/26, and the incident will be discussed at that time. During interviews on 8/12/26, twelve staff members confirmed they have received education and competency evaluation on the facility's abuse and neglect policy. The facility has demonstrated compliance with the above since 7/29/26. Information was reviewed via Plan of Correction documentation. During an interview on 8/12/26, at 2:07 p.m. information was disseminated to the Nursing Home Administrator and DON that the facility failed to ensure Resident R1 was free from neglect by failing to provide adequate staff assistance during med mobility, resulting in a fall from the bed to the floor and the facility had implemented a plan of correction and achieved compliance on 7/29/26, after implementing corrective actions. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs, resulting in a fall for one of four residents (Resident R1).Finding include: Review of facility policy Accidents and Incidents dated 8/12/25, indicated an accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. Review of the facility Bed Mobility Competency checklist indicated employees are to check Kardex (a snapshot of resident care needs) to determine bed mobility. Stand on the side of the bed to which you want to move the resident. If bed mobility is assist of two, one staff member to stand on each side of the bed. If a resident is a bed mobility of two NEVER leave resident alone or perform task/care with assist of one. Review of the facility Nurse Aide Job Description indicated staff are to review care plans and perform nursing care as outlined, assure residents are given adequate assistance with personal and oral hygiene needs following company's policies and procedures and assist residents with activities of daily living as documented in the resident's care plans. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anxiety. Review of a physician order dated 6/5/25, indicated care in pairs at all times each shift for medication and personal hygiene. Review of a physician order dated 5/8/25, indicated low air loss mattress (a specialized support surface used to prevent and treat pressure injuries by continuously circulating a low volume of air), check placement and function QS (every shift). Review of Resident R1's Kardex dated 7/15/26, indicated bed mobility: assist x2 (two staff members), care in pairs, and low air loss mattress. Review of facility submitted documentation dated 7/15/26, indicated the following: At 0700 (7 a.m.) two CNAs (Certified Nurse Aide) went in Resident R1's room to perform ADLs (activities of daily living) with brief change, resident is a care in pairs due to resident's past allegations of abuse in the past and bed mobility assist of 2, requiring 2 people in attendance. AM (morning) care started, then one CNA left room to get supplies and 2nd CNA continued with care, rolling resident onto her left side and resident rolled off bed, landing on the floor. No obvious injury, EMS (emergency medical services) called and took resident to ER (emergency room) for assessment. Review of a staff witness statement, dated 7/15/26, completed by Nurse Aide (NA) Employee E1 stated, Writer went in at 0700 to do AM care on resident while doing care other aide went to get wipes while writer was rolling resident over to the left side then resident rolled out of bed. Nurse walked in while aide was checking on resident, RN (Registered Nurse) was notified. Writer waited with resident, resident was talking and awake until EMS arrived. Review of a staff witness statement, dated 7/15/26, completed by NA Employee E2 stated, I was helping in Resident R1's room to get resident dressed. I went to get wipes and I answered a call light in another resident room. Then people were yelling for me that they needed me in Resident R1's room, and the resident was on the floor. Review of a written verbal statement dated 7/15/26, obtained from NA Employee E1 by Interim Director of Nursing Employee E5 stated, At 0730 (7:30 a.m.) NA Employee E2 and I went into Resident R1's room to do AM care and brief change, NA Employee E2 left to get wipes and I started cleaning her up, rolled resident on to her left side and she rolled off the bed. I didn't know she was a bed mobility of 2 requiring two people to move her in the bed. Review of a staff witness statement dated 7/15/26, completed by Licensed Practical Nurse (LPN) Employee E4 stated, This writer was outside resident's room preparing medications. The aides were doing AM care on resident. Heard a call out for assistance. Upon entering room, resident was on floor in supine position leaning toward right side. Resident was alert and talking. Immediately assessed no open wounds, went to get RN supervisor. Resident remained interactive with staff, expressed being scared, however she was easily reassured. EMS arrived at 0742 (7:42 a.m.) resident left building via ambulance to transport to hospital at 0751 (7:51 a.m.). Review of facility onboarding documentation indicated NA Employee E1 was hired on 10/4/21. During a telephonic interview on 8/12/26, at 11:03 a.m. NA Employee E1 stated, I went in to do morning care with the resident, the air mattress was set a little higher than it should have been, the mattress puffed up and she rolled out of bed. I was not aware that the resident was an assist of two at the time of the incident. I have worked that assignment multiple times before. I work agency for the company, and the company utilizes the same POC (Plan of Care, electronic medical record containing resident care information) throughout all of the facilities. I do know where to look for the POC and I am aware to look at it. The POC tells us how a resident transfers in and out of bed and their bed mobility requirement. I didn't know the resident was a care in pairs until after the situation. Care in pairs means usually two people because something has happened in the past. The direction I roll a resident (away from or towards staff) depends on the resident. Resident R1 has left sided weakness, she can still help with her right hand, she can usually grab the bed rail. During an interview on 8/12/26, at 11:20 a.m. NA Employee E5 stated, To locate resident's bed mobility status, I look in the Kardex in the electronic medical record. We also have binders in every resident hallway with a printout of the Kardex for reference. They are usually kept up to date. I check the Kardex every shift when I come in. We are supposed to have two staff members for residents on an air mattress, so they don't fall off the bed. During care I always roll a resident towards me, I would never roll a resident away from me without having a second person on the other side of the bed. Care in pairs means that we are to have two people in the room at all times. Care in pairs is communicated to the staff in the Kardex and there is also a magnetic tag that is placed outside of the resident rooms to indicate two people are required. During an interview on 8/12/26, at 11:25 a.m. NA Employee E2 stated, To know a resident's bed mobility status, I check the Kardex, it's part of the resident's charting in the electronic medical record, we also have binders in the hallways. Therapy is also pretty good about letting us know if someone's mobility status changes. It is always two staff members with an air mattress. While providing care, I roll the resident towards me, event when it's not an air mattress so I have more control. I would never roll a resident away from myself without a second person on the other side of the bed. Care in pair means two people in the room during care. Most of the time there is a picture outside of the room and it is indicated in the resident's electronic medical record. During an observation on 8/12/26, at 11:35 a.m. a sign was observed outside of Resident R1's room indicating that the resident requires care in pairs. During an interview on 8/12/26, at 11:40 a.m. NA Employee E6 stated, I look in the Kardex to know a resident's mobility status. That should probably be checked every shift before you give care. You have to have two people when you're giving care to a resident on an air mattress. During care I roll the resident towards me when I'm by myself, I would never roll someone away from me when I'm providing care by myself. During an interview on 8/12/26, at 12:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision for bed mobility needs, resulting in a fall for one of four residents (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for three of five residents (Resident R4, R5, and R9).Findings include: Review of facility policy Medication Administration dated 8/12/25, indicated that medications will be administered in accordance with written orders of licensed physicians, manufacturer's specifications, and professional standards of practice. A medication error occurs when a resident receives a medication at an incorrect time, does not receive a medication which was ordered. A locked Emergency Medication Kit is maintained by Quality Pharmacy and is kept in a designated medication room in the facility. Review of the clinical record indicated Resident R4's was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 1/5/26, included diagnoses of anxiety, depression, and diabetes (a condition that causes blood sugar to rise). Review of a physician's order dated 12/3/25, indicated for Resident R4 to receive Insulin Lispro Subcutaneous Solution Pen-Injector 100 unit/milliliter (ml), inject subcutaneously before meals and bedtime for diabetes.as per sliding scale:If less than 70, initiate hypoglycemia protocol,70-140 = 0 units141-180 = 1 units181-220 = 2 units221-260 = 3 units261-300 = 4 units301-340 = 5 units341-600 = 6 unitsGreater than 340, initiate hyperglycemic protocol, call physician. Review of Resident R4's progress note dated 1/13/26, at 1:27 a.m. revealed the resident did not receive Insulin Lispro before bedtime because unable to log into computer- too close to next dose to administer. Review of the clinical record indicated Resident R5's was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 1/5/26, included diagnoses of anxiety, depression, and diabetes (a condition that causes blood sugar to rise). Review of a physician's order dated 11/4/25, indicated for Resident R5 to receive Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-Injector 100 unit/milliliter (ml), inject subcutaneously before meals and bedtime for diabetes as per sliding scale:If 0-140 = 0 units141-180 = 2 units181-220 = 4 units221-260 = 6 units261-300 = 8 units301-350 = 10 units351-400 = 12 units401-999 = 14 units and call physician Review of Resident R5's progress note dated 1/13/26, at 1:20 a.m. revealed the resident did not receive Insulin Lispro before bedtime because patient sleeping. Review of the clinical record indicated Resident R9's was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 12/20/25, included diagnoses of heart failure, high blood pressure, and atrial fibrillation (irregular heartbeat). Review of a physician's order dated 12/14/25, indicated for Resident R9 to receive 6.25 milligram (mg) Carvedilol by mouth two times a day for ventricular tachycardia (irregular heartbeat). Review of Resident R9's January 2026 Medication Administration Record (MAR) revealed Registered Nurse, Employee E1 documented see nurses note on 1/12/26, at 8:00 p.m. Review of Resident R9's progress note dated 1/13/26, at 2:11 a.m. revealed the resident's medication was not available in cart, needs reordered. A review of RN, Employee E1's witness state dated 1/13/26, stated During the scheduled evening medication administration, multiple medications listed as active were not available in the medication cart. At the time of administration, I was not informed that a supplemental emergency medication box was available for use within the facility. RN, Employee E1 stated The eMAR system settings for the evening medication pass did not display all medications that were due during the assigned administration timeframe. Following completion of initial medication pass, a subsequent review if the eMAR identified multiple medications that had not populated during the scheduled pass. This discrepancy was identified at approximately 1:00 a.m. During an interview on 2/23/26, at 9:51 a.m. LPN, Employee E2 stated medications must be administered an hour before or after the scheduled time it is ordered. LPN, Employee E2 stated if residents are sleeping, they must be awakened to take medications. On 2/23/26, at 11:33 a.m. RN, Employee E1 was unavailable for a phone interview. During an interview on 2/24/26, at approximately 2:00 p.m. information was disseminated to the Nursing Home Administrator and Director of Nursing that the facility failed to ensure that residents were free from significant medication errors for three of five residents (R4, R5, and R9.) 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policy and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for 12 out of 14 months. Findings included: Review of facility Infection Prevention Program policy dated 10/13/25, indicated the infection program is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel. During entrance meeting on 11/12/25, at 9:30 a.m. Assistant Director of Nursing (ADON) was identified as the facilities Infection Preventionist (IP). During a review of the facilities Infection Control Program on 11/13/25, the ADON/IP Employee E10 stated, I just started in this role. I completed my infection control training but couldn't take a test and I couldn't print a certificate. During a review of IP certificates reveal the facility failed to have a certified IP on the following dates: - September 2024 - 6/26/25 - 7/26/25 - 8/19/25 - 10/11/25 - 11/13/25 On 11/13/25 the ADON/IP Employee E10 provided a Nursing Home Infection Preventionist Training Certificate dated 11/13/25. During an interview on 11/13/25, at 12:45 p.m. the Director of Nursing confirmed the above dates and that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for 12 out of 14 months. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to one of five residents (Residents R31).Findings include:Review of the facility policy Standing Orders for Administering Influenza Vaccine to Adults dated 10/13/25, indicated to reduce morbidity and mortality from influenza by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Advisory Committee on Immunization Practices.Review of the facility policy Standing Orders for Administering Pneumococcal Vaccine to Adults dated 10/13/25, indicated to reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Advisory Committee on Immunization Practices.Review of the admission record indicated Resident R31 admitted to the facility on [DATE].Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/7/25, indicated the diagnoses of Parkinson's disease (disorder of the nervous system that results in tremors), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and high blood pressure.Review of Resident R31's clinical record on 11/14/25, at 10:00 a.m. failed to include documented evidence that the influenza immunization and pneumococcal immunization were offered, administered, or declined by the resident.Interview on 11/14/25, at 12:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that influenza immunization and pneumococcal immunization were offered to one of five residents (Residents R31).28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for the facilities Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias) and crash cart (a supply cart used in an emergency).Findings include: Review of facility AED policy dated 10/13/25, indicated the AED will be available for use in emergency situations and its function maintained according to manufacturer recommendations. Daily maintenance includes checking the indicator to ensure that it is green (AED is ready for rescue). Perform maintenance to the AED monthly. During an observation of the facilities AED box on 11/12/25, at 12:05 p.m. revealed an AED with electrodes attached to the machine were present. An extra set of electrodes were in the AED box. The facility failed to provide documentation for the daily and monthly checks to ensure the AED is in working order. During an observation of the facilities crash cart, located on Liberty Nursing Unit, on 11/12/25, at 12:30 p.m. revealed the crash cart was checked on 9/27/25, 10/4/25, 10/20/25,10/24/25, 10/27/25, and 11/10/25. During an interview on 11/12/25, at 12:44 p.m. Licensed Practical Nurse Employee E1 confirmed the above dates and stated that the crash cart should be checked daily by nursing staff. During an interview on 11/12/25, at 2:15 p.m. the Director of Nursing confirmed that the facility failed to make certain that equipment was in safe operating condition for the facilities Automated External Defibrillator and crash cart. 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for one of five staff members (Nurse Aide (NA) Employee E3).Findings include:Review of facility provided documents and training records for NA Employee E3 on 11/14/25, indicated that NA Employee E3 was hired to the facility on 7/12/17, and failed to include education on effective communication as required.Interview on 11/14/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for one of five staff members (NA Employee E3). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medication rooms (Liberty Medication Room) and one of three medication carts (Market Place Medication Cart).Findings include:Review of facility policy Medication Storage in the Facility dated 8/18/25, indicated certain medications such as multiple dose vials, ophthalmic solutions, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. During an observation on 11/12/25, at 11:45 a.m. of the Liberty Medication Room Refrigerator revealed a tuberculin multiple dose vial (a substance used in the tuberculin skin test (TST) to diagnose tuberculosis infection) that was opened and not labeled with the date opened as required.Interview on 11/12/25, at 11:46 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the tuberculin multiple dose vial was opened and not labeled with the date opened as required.During an observation on 11/12/25, at 12:20 p.m. of the Market Place Medication Cart the following was observed:-Cyclosporine eye ointment (increases natural tear production) opened and without the date opened.-Budesonide (inhalant used to reduce inflammation to make breathing easier) solution opened and without the date opened.During an interview on 11/12/25, at 12:21 p.m. LPN Employee E2 confirmed the above observation and that the facility failed to properly store medication in one of three medication carts.During an interview on 11/12/25, at 2:00 p.m. the Director of Nursing confirmed the facility failed to properly store medications in one of two medication rooms (Liberty Medication Room) and one of three medication carts (Market Place Medication Cart).28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for one of four residents reviewed (Resident R27).Findings include:Review of the facility policy Fluid Restriction dated 10/13/25, indicated when a physician orders a fluid restriction due to specific clinical condition, close monitoring will be provided to maintain adequate hydration. The water pitcher is to be removed from the bedside. Dietary will determine desired beverages at meals and the remaining amount of fluids to be provided by nursing. Calculate amount allotted for each shift.Review of the admission record indicated Resident R27 was admitted to the facility on [DATE], with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), End Stage Renal Disease (ESRD - kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R27's physician's order dated 11/12/25, indicated a 1200 milliliter (ml) daily fluid restriction. The order failed to include allotted amount for each shift for nursing staff.Review of Resident R27's care plan dated 11/13/25, indicated resident has a nutritional problem related to ESRD anddialysis dependence. Intervention of fluid restriction 1200 mls per day. The care plan failed to include allotted amount for each shift for nursing staff.Observation on 11/14/25, at 9:30 a.m. Resident R27 was in bed with a water pitcher on the bedside stand and a can of ginger ale.Interview on 11/14/25, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E1 indicated Resident R27 is on a fluid restriction of 1200 ml a day and should not have a water pitcher in the room. When asked how much nursing is permitted to provide LPN Employee E1 could not provide an amount and indicated the order was for 1200 ml/day and was not broken down into each shift.Interview on 11/14/25, at 11:00 a.m. the Director of Nursing confirmed the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for one of four residents reviewed (Resident R27).28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, incident reports, facility documents, employee education, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of four residents (Resident R39).Findings include: Review of the facility Accidents and Incidents policy dated 10/13/25, indicated that the facility will promote a safe environment for all residents. An accident or incident is any happening, which is not consistent with routine operations or the routine care of the particular resident. Review of Resident R39 clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R39's clinical record MDS (minimum data set a periodic assessment of resident needs) dated 9/25/25, indicated diagnosis of high blood pressure, coronary artery disease (damage or disease in the heart's major blood vessels), and unsteadiness on feet. Review of Resident R39's care plan dated 3/25/25, indicated transfers assist times two with handheld assist for my safety. Review of a written witness statement dated 4/17/25, from Licensed Practical Nurse (LPN) Employee E11 stated, Writer was passing medications on floor where resident resides. Residents call light going off for several minutes. Resident stated she needed to use the restroom. Resident scooted self to edge of bed and placed feet on the floor. Writer unable to locate any assistance. Resident knees began to buckle and sat on writers stabilized knee. Resident was able to get up and shifted to her wheelchair. Small skin tear noted to left lower extremity. Physician notified and new orders received for treatment of a skin tear. During an interview on 11/13/25, at 2:33 p.m. Nurse Aide (NA) Employee E12 stated that a residents transfer status could be located on the Kardex or in the computer. I would not transfer resident myself if they were a two person assist. They could fall and get hurt. You could injure them like a skin tear too. During an interview on 11/13/25, at 2:35 p.m.NA Employee E13 stated you could find transfer status on the computer or on paper at the nurse's station. If someone was an assist of two, I would not transfer them myself. They could fall. During an interview on 11/13/25, at 2:40 p.m. the Director of Nursing confirmed that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of four residents (Resident R39). 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a) Resident rights. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased Capillary Blood Glucose (CBG) levels for one of three residents reviewed (Residents R31), and failed to make certain that residents were provided appropriate treatment and care by failing to obtain an X-ray in an appropriate timeframe for one of four residents (Resident Closed Record (CR) R100). Findings include: Review of the facility policy Physician Notification dated 10/13/25, indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. Review of facility policy Your Rights and Protections as a Nursing Home Resident policy dated 10/13/25, indicated residents have the right to be treated with dignity and respect. You have the right to get proper medical care. Review of the admission record indicated Resident R31 admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/7/25, indicated the diagnoses of Parkinson's disease (disorder of the nervous system that results in tremors), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and high blood pressure. Review of Resident R31's physician order dated 11/4/25, indicated Insulin Lispro (a short acting, manmade version of human insulin) Pen-injector 100 UNIT/ML (milliliter) inject as per sliding scale: if 0 - 140 = 0 units; 141 - 180 = 2units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12units; 401 - 999 = 14 units give 14 units and call MD. Review of Resident R31's current care plan indicated resident will be free from any signs orsymptoms of hyperglycemia (too much glucose in the blood) or hypoglycemia (not enough glucose in the blood) through the next review date. Intervention to administer resident's diabetes medications as ordered. Monitor for effectiveness and the occurrence of any side effects and report them to my physician. Review of Resident R31's CBG's results indicated the following:-11/7/25, at 11:58 a.m. CBG of 407.-11/8/25, at 11:31 a.m. CBG of 460. Review of Resident R31's clinical record failed to indicate the physician was notified of CBG's over 401 as ordered on 11/7/25, and 11/8/25. Interview on 11/14/25, at 10:27 a.m. the Director of Nursing confirmed that the facility failed to notify physicians of increased Capillary Blood Glucose (CBG) levels for one of three residents reviewed (Residents R31). Review of the clinical record indicated Resident R100 was admitted to the facility on [DATE] and was discharged from facility on 10/14/25. Review of Resident 's R100's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/14/25, indicated diagnoses of depression, unsteadiness on feet, and a right fracture of tibia (one of the bones in a person's lower leg). During a review of Resident R100's clinical record on 11/13/25, at 2:01 p.m. indicated resident had a witnessed fall in her room on 9/25/25. Resident slid out of chair, while wearing a leg immobilizer. Resident was experiencing pain and was currently being treated for a tibia fracture. During a review of Resident R100's physician orders dated 9/25/25, indicated Xray to right lower extremity due to pain. During a review of Resident R100's progress notes on 11/14/25, at 9:01 a.m. indicated that a mobile x-ray was completed on 9/26/25. On 9/30/25, nursing staff determined that the x ray was completed on the wrong resident, notified physician and obtained a new order. Mobile X-ray completed new imaging on 9/30/25, five days later. During an interview on 11/14/25, 12:15 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and care by failing to obtain an X-ray in an appropriate timeframe for one of four residents (Resident R100). 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R39).Findings included: Review of the facility Resource: Audit to Assess Quality Care Provided policy dated 10/13/25, indicated care plans are modified when indicated. Care plan revision includes identification of changes in the individual's condition that require revised goals and care approaches. Review of Resident R39 clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R39's clinical record MDS (minimum data set a periodic assessment of resident needs) dated 9/25/25, indicated diagnosis of high blood pressure, coronary artery disease (damage or disease in the heart's major blood vessels), and unsteadiness on feet. Review of Resident R39's care plan initiated on 3/25/25, indicated resident transfers assist of two with handheld assist for my safety. Review of Resident R39's Physician Orders dated 4/22/25, indicated Activities/Mobility: Transfers with mechanical Sit to Stand lift with assist times two. During an interview on 11/14/25, at 9:45 a.m. Licensed Practical Nurse Assessment Coordinator Employee E9 reviewed Resident R39's care plan and stated that the transfer status should have been updated to reflect current physician orders. During an interview on 11/14/25, at 12:46 p.m. the Director of Nursing confirmed the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R39). 28 Pa. Code 201.24(e)(1)(5) Admissions Policy28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for one of six residents (Resident R42).Findings include: Review of the facility Activities of Daily Living policy dated 10/13/25, indicated a program of activities of daily (ADL) living is provided for residents. A program of assistance in ADL skills is implemented. Residents are encouraged to eat in the group dining room, when possible, for socialization. Review of the facility Your rights and Protections as a Nursing Home Resident policy dated 10/13/25, indicated a resident has the right to be treated with dignity and respect. Review of Resident R42's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R42's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/2/24, indicated diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain), hyperlipidemia (a high level of fats in the blood), and dysphagia (difficulty swallowing). Section GG Functional Abilities GG0130 Eating was coded as a 2, indicating resident requires substantial maximal assistance and the helper does more than half the effort. During an observation on 11/12/25, at 12:06 p.m. six residents were sitting at a table together for lunch. All residents were served and started to eat their lunch at the same time except for Resident R42. During an interview on 11/12/25, at 12:09 p.m. Graduate Nurse Aide Employee E5 stated Resident R42's lunch was still on the lunch cart and We don't want to set it out and get cold until we can get to feeding him. He needs help to eat. During an interview on 11/12/25, at 12:10 p.m. Licensed Practical Nurse Employee E1 stated, They shouldn't have had everyone else eat in from of him. They should have brought him out to the table when they were ready to feed him, and all the residents were eating together at the same time. During an interview on 11/12/24, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide a dignified dining experience by failing to provide assistance with meals timely for one of six residents (Resident R42). 28 Pa Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents (Resident R25) with an indwelling foley catheter.Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents (Resident R25) with an indwelling foley catheter.Findings include:Review of the facility policy Enhanced Barrier Precautions dated 10/13/25, indicated enhanced barrier precautions (EBP) are used and expand the use of Personal Protective Equipment (PPE) to donning (putting on) of the gown and gloves during high-contact resident care activities that provide opportunities for transfers of multi-drug-resistant organisms to staff hands and clothing. Examples of high-contact resident care activities requiring EBP includes device care or use (central lines, urinary catheter, supra-pubic catheter, feeding tube or tracheostomy.Review of the admission record indicated that Resident R25 was admitted to the facility on [DATE], with the diagnoses of urinary tract infection, rib fractures, and neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem).Review of Resident R25's physician order dated 11/6/25, indicated foley catheter (a thin, flexible tube inserted into the bladder to drain urine) for neurogenetic bladder. Size 16 French (outer diameter of the tube) with 10 cc (cubic centimeter) balloon.Review of Resident R25's current care plan indicated resident has an Indwelling catheter for neurogenic bladder. Goal of remaining free from catheter-related trauma.Observation on 11/12/25, at 10:00 a.m. Resident R25 was observed in bed with an indwelling catheter bag attached to the bed.Interview on 11/12/25, at 10:05 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R25 had a foley catheter.Interview on 11/12/25, at 2:00 p.m. the Director of Nursing confirmed that Resident R25 was not on the EBP listing and did not have a physician order for EBP as required and that facility failed to follow enhanced barrier precautions for one of two residents (Resident R25) with an indwelling foley catheter. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of facility policies, documents, resident medical records and staff interviews, it was detrmined that the facility failed to implement an abuse and neglect policy to properly investigation of a physical injury or unknown origin for one of 59 residents (Resident R1). Finding include: During a review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation date 11/21/24, it was revealed that the facility is to implement and complete an investigation for serious physical injury that has resulted in pain, and impairs physical functioning temporally or permanently. The results of the investigation including reports and PB22s must be completed with in five working days. During a review Resident R1's progress notes it was revealed that on 2/16/25, the resident sustained a serious physical injury of unknown origin resulting from transfer procedures from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her shoulder resulting in pain and edema of her right hand. A hospital emergency room evaluation confirmed that the residnet sustained a displaced right humeral fracture. A review of facility documents failed to provide evidence of the facility implementing an investigation of Resident R1's serious physical injury or unknown origin. The facility failed to provide documented evidence of the results of a through investigation and the competition and submission of a PB 22 for each alleged perpetrator identified as required. During an interview on 3/11/25, at 10:45 am Corporate Clinical Coordinator Employee E1 confirmed that the facility failed to implement their abuse or neglect policy and procedure to thoroughly investigate a resident's physical injury of unknown origin. She confirmed that the facility failed to provide documented evidence of the results of a through investigation which was to include documented evidence to verify the alleged perpetrator preformed return demonstration of the transfer procedure for Resident R1 and the submission of PB 22 forms for each identified alleged perpetrator as required. PA Code: 201.14(c)(d)(e) Responsibility of Licensee

Based on a review of facility policies, documents, resident medical records, and staff interviews it was determined that the facility failed to identify and determine the root cause of a physical injury as the potential for abuse or neglect for one of 59 residents. (Resident R1) Findings include: A review of facility Resident Protection from Abuse, Neglect, Mistreatment or Exploitation policy dated 11/21/24, revealed that serious physical injuries are to be reported to the state agency, investigated and PB 22s completed for each alleged perpetrator. A review of the facility's documents revealed that on 2/16/25, Resident R1 sustained a serious physical injury while being transferred from her bed to a wheelchair. While pivoting during the transfer procedure the resident heard and felt a loud crack in her right shoulder. Due to the resident's increased pain and edema to her right hand the facility obtain a physician order for an xray. The xray revealed a displaced 2.2 X 1.3 centimeter avulsion fracture of the lateral aspect of the humeral head in the right shoulder. Resident R1 was transferred to the hospital for further evaluation. A review of the state agency reporting documents revealed that the facility notified the state agency that Resident R1 was transferred to the hospital for an evaluation which resulted in confirmation by the hospital of a displaced right humeral fracture. The notifying document submit to the state agency indicated Resident R1's transfer to the hospital and failed to properly be reported as alleged abuse or neglect as required for serious physical injuries with unknown origin of the injury. A review of the facility's documents failed to provide documented evidence that the facility implemented a root cause analysis of Resident R1's serious physical injury which resulted in the potential for other residents to be at risk for abuse or neglect. During an interview on 3/11/25, at 9:15 am the Corporate Clinical Coordinator Employee E1 and Nursing Home Administrator confirmed that the facility failed to notify the state agency of the potential for abuse or neglect to Resident R1 as the result of a physical injury of unknown origin and the facility's failure to identify the incident as the potential for abuse or neglect with the potential for other residents to be at risk. Pa Code: 201.18(b)(1)(2) Management.

Based on review of facility policy, resident clinical records, investigation documents and staff interview, it was determined that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) reviewed. Findings include: Review of facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 11/21/24, indicated that nursing homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our resident, each home will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. All reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source, and misappropriation of resident property will be investigated and documented. The Administrator or Director of Nursing will notify the PA Department of Health/Long Term Care Division via electronic reporting system (ERS) within 24 hours of the incident. Review of Title 42 Code of Federal Regulations (CFR) S483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the clinical record indicated that Resident R1 was admitted to the facility 9/9/22. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/22/24, indicated diagnoses of spinal stenosis (condition characterized by the narrowing of spaces in the spine, which can compress the spinal cord and nerves), dysphagia (difficulty swallowing), and generalized muscle weakness. Review of Resident R1's clinical progress note dated 1/8/25, indicated Resident R1 was assessed for one or more wounds that are non-pressure related. Resident has a wound on the chest:right breast/side and front of shoulder. 01/08/2025 is when the wound was found acquired in-house. Dark purple bruising to bottom, yellow on top. The primary tissue type is 100% intact. This presents as bruising. Review of an incident report dated 1/8/25, indicated nurse on unit was alerted that resident (R1) had a bruised area. Upon assessment writer observed a large bruise from the right shoulder, along the right side, breast and under the breast. Observed yellow coloring to the top then into a dark purple for the remainder of the area. The document did not include that the State office had been notified of the injury of unknown source. Review of the clinical record indicated that Resident R2 was admitted to the facility 2/24/23. Review of Resident R2's MDS dated [DATE], indicated diagnoses of hypo-osmolality (condition where the plasma osmolality is low) and hyponatremia (condition when the sodium concentration in the blood is low), altered mental status, and lack of coordination. Review of Resident R2's clinical progress note dated 1/11/25, at 5:50 a.m., indicated that resident (R2) has bruising to right arm and left hand. Right upper forearm with 4 cm (centimeter) x 2.5 cm bruise noted. Scattered bruising to lower right forearm and back of left hand. No injury witnessed. Review of incident report dated 1/11/25, indicated scattered bruising to right upper forearm with 4 cm x 2.5 cm bruise noted. Scattered bruising to lower right forearm and left hand noted. Reported by Nurse Aide (NA). The document did not include that the State office had been notified of the injury of unknown source. Review of the clinical record indicated that Resident R3 was admitted to the facility 2/28/23. Review of Resident R3's MDS dated [DATE], indicated diagnoses of aortic stenosis (condition where the aortic valve in the heart is narrowed or blocked), Alzheimer's disease (neurologic disorder that causes irreversible changes in memory, thinking, and behavior), and diabetes mellitus (group of diseases that affect how the body uses blood sugar). Review of Resident R3's clinical progress note dated 1/16/25, indicated writer was informed of bruising to resident right underarm area. Bruising is in line with straps of STS (Sit-to-stand) lift, which resident was using up until 6 days ago. Bruising partially surrounds right axilla, running along upper inner right arm and off to the side of right breast, and is varying degrees of color ranging from dark purple to greenish. Review of incident report dated 1/16/25, indicated that writer was informed by Nurse Aide (NA) of bruising to resident (R3) right underarm area. Bruising is in line with straps of STS (Sit-to-stand) lift, which resident was using up until 6 days ago. Bruising partially surrounds right axilla, running along upper inner right arm and off to the side of right breast, and is varying degrees of color ranging from dark purple to greenish. The document did not include that the State office had been notified of the injury of unknown source. Review of the reporting system for the facility's state survey agency did not show evidence that the state survey agency was notified, and the results of any investigation was reported regarding the referenced injuries of unknown source. During an interview on 1/28/25, at 1:00 p.m., the Director of Nursing (DON) confirmed that the facility failed to report injuries of unknown source for three of three residents (Resident R1, R2, and R3) as required. 28 Pa Code: 201.14 (a) Responsibility of Management 28 Pa Code: 201.18 (e )(1) Management.

Based on review of facility policy, resident grievances for 60 days, resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed. Findings include: Review of facility policy Communication of Resident, Family and Staff Concerns and Grievances dated 8/17/23, indicated to encourage residents, family members and staff to ask questions and express their concerns will maximize their quality of care and promote higher levels of staff and customer satisfaction through timely responses to questions and resolution of issues concerns and grievances. Once we receive a grievance, we will make every effort to respond as quickly and effectively as we can with the goal of always providing outstanding customer service. Our goal is to resolve all concerns within five days of the report with all parties in agreement of the resolution, If the concern cannot be resolved in five days, the reason must be documented on the Concern form and the resident or resident representative notified of the delay in resolution. Review of the facility's Grievance/Complaint Logs for October and November of 2024 indicated the following grievance had not been responded to in a timely manner: -10/27/24: Resident R1 filed a Concern Form stating she did not receive medication until around lunch. Blood sugar was not checked on daylight. States she had to ask the nurse for her medications. The Concern form Outcome of Investigation, Signature of person completing investigation and date, Was the concern confirmed, partially confirmed or not confirmed, Corrective action taken, Resolution, Resolution reviewed with resident or family, Did resident receive a written decision sections were all blank. The facility failed to provide documented evidence that they made prompt efforts to resolve Resident R1's grievance. During review of the concern form on 11/19/24, at 1:05 p.m. revealed the Nursing Home Administrator and Social service signatures were missing and documented on concern log was blank. During an interview on 11/19/24, at 1:10 p.m. the Director of Nursing (DON) confirmed that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for one of three grievances reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 PA Code: 201.29(j) Resident rights.

Based on review of facility policy, clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to thoroughly investigate a potential allegation of abuse/neglect for misappropriation of property for one of two residents reviewed (Resident R37). Findings include: Review of facility policy Resident Protection From Abuse, Neglect, Mistreatment or Exploitation dated 12/1/23, indicated misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Abuse, neglect, misappropriation of property and exploitation will be identified through various methods including reports from employed or contracted staff. All reports of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property will be investigated and documented. All investigations will be conducted thoroughly and will attempt to gather as much factual information as possible. Review of facility policy Management of Controlled Drugs dated 12/1/23, indicated to destroy the drug with another licensed staff member as witness. Staff member designated as witness to the destruction must actually witness the waste. Document the reason for the destruction on the controlled drug inventory in the space for that dose. Signature of person who poured and destroyed the drug and signature of witness must be entered in the space with the documentation of the destruction. Perform a complete count of all controlled drugs at the change of shifts or at any time in which narcotic keys are surrendered from one staff member to another. Count must be performed by two licensed nurses per state regulations. Both licensed nurses participating in the count must sign the individual inventory at the time of the count. If discrepancy is noted during the count, notify nursing supervisor immediately to initiate investigation. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/27/24, indicated diagnoses of high blood pressure, muscle wasting, and unsteadiness on feet. Review of a physician's order dated 8/10/23, indicated to administer Morphine Sulfate (a controlled pain medication) 10 milligrams sublingually (under the tongue) every two hours as needed for moderate pain or shortness of breath. Review of an event submitted by the facility dated 1/30/24, stated, During shift change this morning while off going and oncoming nurses were doing narcotic count, the oncoming nurse noted the color of the Morphine for Resident R37, that the color was not blue but a charcoal color. The oncoming nurse states when she counted the same cart on 1/26/24 that the Morphine was blue. Nurse alerted supervisor immediately. Review of the Controlled Drug Record for Resident R37's Morphine Sulfate revealed the amount was adjusted from 20 milliliters (mL) to 18 mL with a documented reason of spillage/dehydration. No date, time, or witness signature were documented for this entry. Review of an additional entry to the Controlled Drug Record for Resident R37's Morphine Sulfate revealed the amount was adjusted from 18 mL to 16 mL with a documented reason of spillage/dehydration. No date or time were documented for this entry. Review of a written witness statement dated 1/31/24, completed by Licensed Practical Nurse (LPN) Employee E6 stated, On the days I have been scheduled on Pennsylvania [nursing unit] I have not had the narcotic keys and have not participated in count. I was on other halls when count was performed, so I did not notice any discrepancies. There have been times nurses don't want to do count at the end and say it's ok, and they next take the keys. Review of a written witness statement dated 1/31/24, completed by LPN E4 stated, On Sunday January 28, Registered Nurse (RN) Employee E10 had the Liberty [nursing unit] narc keys, and when she was being sent home at 11:00 p.m. she gave me the keys. She did not want to count the narcs. I went over to Liberty cart and counted them myself. During an interview on 9/27/24, at 9:50 a.m. when asked if additional statements were obtained regarding accusations that nursing staff refuses to perform end-of-shift narcotic count, the Nursing Home Administrator stated, I'm not sure, but I bet it was investigated because my Director of Nursing at the time was pretty good about that stuff. The facility failed to provide additional documentation to indicate the accusations that nursing staff refuse to perform end-of-shift narcotic count was thoroughly investigated. During an interview on 9/27/24, at 12:55 p.m. Clinical Consultant Employee E2 stated, We provided education to the nursing staff in March that end-of-shift narcotic count is a requirement. During an interview on 9/27/24, at 12:55 p.m. the NHA confirmed that the facility failed to thoroughly investigate a potential allegation of abuse/neglect for misappropriation of property as required. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.14 (c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to notify a physician of abnormal glucose levels as per physician's order for two out of five residents (Residents R20 and R33). Findings include: Review of the facility policy Physician Notification dated 12/1/23, indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. Review of the facility policy Hypoglycemia Protocol dated 12/1/23, indicated for hypoglycemia (a blood glucose less than or equal to 70 mg/dl (milligrams/deciliter), and hyperglycemia a more common side effect, should recheck the blood sugar and notify the physician. Review of Resident R33's admission record indicated an admitted [DATE], with diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of R33's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/5/24, indicated the diagnoses remain current. Review of Resident R33's current physician orders on 9/26/24, indicated Glucagon (medication to raise blood sugar) Emergency Kit, inject 1 mg subcutaneously as needed for hypoglycemia diabetes. Call physician. Review of Resident R33's progress notes dated 8/26/24, at 2:45 a.m. resident complained of not feeling well to Nurse Aide (NA). Resident was diaphoretic (sweating heavily), slurring his words. Upon assessment blood sugar was at 48 mg/dl. A cup of orange juice and carbohydrate snack were provided. Registered Nurse (RN) made aware. Further review of Resident R33's clinical record, failed to include notification to the physician of the abnormal blood glucose as required. Review of Resident R20's admission record indicated she was originally admitted on [DATE], with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), chronic respiratory failure, and anemia. Review of Resident R20's MDS assessment dated [DATE], indicated that the diagnoses were current upon review. Review of Resident R20's physician order's dated 8/15/24, indicated to inject Humulin R Injection Solution 100 UNIT/ML(Insulin Regular(Human). Inject as per sliding scale: 70 - 150 = 0 Glucose < 70 follow hypoglycemia protocol; 151 - 200 = 4 201- 250 = 8 251 - 300 = 12 301 - 350 = 16 351 - 400 =20 >400, give 24u and call provider if >400 Review of Resident R20's blood glucose monitoring documentation for September 2024, indicated the following abnormal glucose levels: 9/2 471 9/15 419 9/16 452 9/17 416 9/21 429 9/24 482 Review of Resident R20's clinical nurse notes, physician notes, and Certified Registered Nurse Practitioner (CRNP) documentation did not include a notification to the physician about the abnormal glucose levels on 9/2/24, 9/15/24, 9/16/24, 9/17/24, 9/21/24 and 9/24/24. During an interview on 9/26/24, at 1:00 p.m. Clinical Consultant Employee E2 confirmed the facility failed to notify the physician of abnormal glucose level as required for Resident R20. During an interview on 9/27/24, at 12:55 p.m. Clinical Consultant Employee E2 confirmed that the facility failed to notify a physician of abnormal glucose levels for as per physician's order for two out of five residents (Residents R20 and R33). 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.