Every finding on record at Quarryville Presbyterian Retirement Community

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (main kitchen). Findings include: The facility's policy for ice machines, dated March 31, 2025, revealed that every month the ice machines were to have the ice removed, the inside of the machine washed with sanitizing solution and a clean cloth, allowed to dry, and then refilled with ice. A third party vendor would come in quarterly and as needed to service the ice machine. A Service log, dated March 3, 2025, revealed that preventative maintenance was performed by a contracted service. There was no documented evidence that the ice machine was cleaned on a monthly basis. Observations on August 27, 2025, at 9:02 a.m. revealed that inside the ice machine there was a build up of a pink substance on the right hand corner of the white plastic piece and a build up of a black substance on the entire length of the strip at the top of the ice machine. The chest was full of ice. Interview with Dietary Manager at that time confirmed that the ice machine needed cleaned. 28 Pa. Code 211.6(f) Dietary services.

Based on review of Resident Council meeting minutes and information provided to residents, as well as resident and staff interviews, it was determined that the facility failed to act promptly upon the grievances of the Resident Council. Findings Include: Resident Council meeting minutes for June 30, July 28 and August 25, 2025, revealed that residents brought up repeat concerns regarding food temperatures and flies in the dining room. During each meeting the residents were reminded that any dining concerns with food temperatures were to be brought to their attention immediately so they could make necessary adjustments at the time of the complaint. The residents were also reminded that there was regularly scheduled pest control visits and multiple remedies in place to control the flies as best as possible. At June's meeting they were to notify the pest control company. An interview with a group of residents on August 28, 2025, at 11:30 a.m. revealed that the food was not hot and they brought flies up three times and the facility didn't do anything about it. Pest control records for June 20, July 18, and August 15, 2025 revealed there was no treatment for flies There was no documented evidence provided to show that prompt efforts were made to resolve the Resident Council's concerns, regarding food temperatures and flies, when they were expressed during the meetings on June 30, July 28 and August 25, 2025. Interview with the Assistant Nursing Home Administrator on August 29, 2025 at 3:02 p.m. revealed that a fly catcher was purchased in June; however there were no new interventions put into place in July and August. Interview with the Nursing Home Administrator on August 30, 2025, at 11:08 a.m. revealed that tray audits were done on June 15 and July 16, 2025 and that the President of Resident Council complains at every meeting. 28 Pa. Code 201.29(i) Resident rights.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 39 residents reviewed (Residents 3, 28, 36 and 78).Findings Include: A facility policy for psychotropic medication management dated March 31, 2025, indicated that the facility will minimize the use of psychotropic medications, avoid unnecessary drug use, and promote the use of non-pharmacological interventions whenever possible. Psychotropic medications include antipsychotics (class of drugs used to treat mental health conditions), antianxiety medications, antidepressants, and hypnotics (induce sleep and sedation). Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed for agitation. Review of Resident 3’s Medication Administration Record (MAR) for May 2025 through July 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., June 24 at 3:54 p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., and July 7 at 3:35 a.m. Resident 3’s Ativan was ordered on May 30, 2025, and extended through August 1, 2025. There was no documented evidence that a physician provided a rationale to extend the medication past 14 days. An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed to ensure that Resident 3’s as needed psychotropic medication was limited to 14 days or had a clinical rationale for continuing beyond 14 days. Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed for agitation. A care plan for the resident, dated March 24, 2025, revealed that the resident was taking psychotropic medications and staff were to offer non-pharmacological interventions prior to medication administration. Review of Resident 3’s MAR for May 2025 through August 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., July 7 at 3:35 a.m., and August 16 at 8:00 p.m. Review of Resident 3’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 3 on the above-mentioned dates/times. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 28 dated June 6, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included dementia. Physician’s orders for Resident 28 dated August 4, 2025, included for the resident to receive 0.25 milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. There was no documented evidence that a physician provided a rationale to extend the medication past 14 days. Review of the Medication Administration Record (MAR) for Resident 28 dated August 2025, revealed that the resident was administered 0.25 mg of Ativan on August 24, 2025, at 3:58 p.m. An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed to ensure that Resident 28’s as needed psychotropic medication was limited to 14 days or had a clinical rationale for continuing beyond 14 days. An admission MDS assessment for Resident 36, dated August 25, 2025, revealed that the resident was cognitively impaired, was rarely/never, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer’s dementia and anxiety. A care plan for the resident, dated August 18, 2025, revealed that the resident was taking psychotropic medications and staff were to offer non-pharmacological interventions prior to medication administration. Physician’s orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive 0.25 mg of Ativan three times daily as needed for anxiety and agitation. Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of Ativan on August 23 at 1:17 p.m., August 25 at 3:32 p.m., and August 27 at 8:39 p.m. Review of Resident 36’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Physician’s orders for Resident 36, dated August 25, 2025, revealed that the resident was to receive 0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for anxiety/agitation. Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29 at 12:30 p.m. Review of Resident 36’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 4:02 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 36 on the above-mentioned dates/times. An annual MDS assessment for Resident 78, dated June 25, 2025, revealed that the resident was cognitively impaired, was sometime understood, could sometimes understand, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer’s dementia, depression, and anxiety A psychiatry consult dated March 14, 2025, for Resident 78 indicated that the facility and their staff were to utilize non pharmacological interventions, supportive care, and redirection. Physician’s orders for Resident 78, dated May 12, 2025 and August 18, 2025, revealed that the resident was to receive 0.5 mg of Ativan every eight hours as needed for anxiety. Review of Resident 78’s MAR for July and August 2025, revealed that the resident received 0.25 mg of Ativan on July 26 at 9:32 p.m., August 21 at 9:53 p.m., and August 21at 11:29 p.m. Review of Resident 78’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 78 on the above-mentioned dates/times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards others, took antipsychotic (medications used to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications, and had diagnoses that included Alzheimer’s dementia, depression, and anxiety. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 39 residents reviewed (Residents 101). Findings include: An admission note for Resident 101, dated August 21, 2025, at 12:16 p.m., revealed that the resident arrived at the facility and had sinusitis (an inflammation of the sinuses) and was going to receive medication for three more days. A current care plan for the resident, dated August 21, 2025, indicated that the resident had an infection diagnosed as sinusitis. A progress note for Resident 101, dated August 22, 2025, at 3:01 p.m. revealed that the resident was positive for COVID and was in respiratory isolation. Observations during the facility tour on August 27, 2025, at 11:34 a.m. revealed a stop sign on Resident 101's door. Interview with staff during the tour indicated that the resident was placed on droplet precautions due to testing positive for covid on admission. There was no documented evidence in the resident's clinical record that a baseline care plan was implemented related to the resident's positive COVID diagnosis and his need for droplet precautions. Interview with the Assistant Director of Nursing on August 30, 2025, at 1:08 p.m. confirmed that a baseline care plan was not implemented for Resident 101 related to his positive COVID diagnosis after admission. She indicated that he had a diagnosis of sinusitis on admission, and the care plan was not revised to reflect that he had COVID and was on droplet precautions. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete nurse aide registry verification for one of three new nurse aides reviewed (Nurse Aide XX) and failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurses reviewed (Registered Nurse XX).Findings include:The facility's policy regarding abuse prohibition, dated March 31, 2025, indicated that the prior to the first day of employment, the facility would verify with the Pennsylvania Department of Health Nurse Aid Registry the standing/certification of all applicants offered employment as a nurse aide. The facility would not employ individuals who had a finding entered in the nurse aide registry or who had a disciplinary action in effect against their professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of their property or mistreatment of residentsThe personnel file for Nurse Aide E3 revealed that she was hired as a nurse aide on May 11, 2025, and there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to hire. The personnel file for Registered Nurse E4 revealed she was hired as a registered nurse on June 1, 2025. There was no documented evidence that her licensure status was checked with the State Board (Texas).Interview with the Director of Human Resources on August 27, 2025, at 1:19 p.m. and 2:09 p.m. confirmed that Nurse Aide E3's standing on the Pennsylvania Nurse Aide Registry was not verified prior to her hire and Registered Nurse E4's licensure status was not checked prior to hire.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that a toileting program was followed to maintain a resident's continence for one of 39 residents reviewed (Resident 24). Findings include: A facility policy related to restorative nursing programs, dated March 31, 2025, indicated that facility provides individualized restorative nursing interventions in accordance with resident needs, care plans, and regulatory requirements to promote and maintain the highest level of physical, mental and psychosocial functioning for residents. Restorative interventions may include bowel and bladder programs that consist of training and toileting schedules. Restorative programs will be carried out by trained restorative nursing assistants, nurse aides, or licensed staff as delegated. Restorative interventions, frequency, and outcomes will be documented in the medical record per facility policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated August 12, 2025, revealed that the resident was mildly cognitively impaired, was clearly understood and able to clearly understand others, was dependent on staff for toileting transfers and hygiene, was on a toileting program, was frequently incontinent of urine, and had a diagnosis of Parkinsonism (a neurological disorder causing slowed movements, stiffness and tremors) and dementia. A care plan for the resident, dated September 6, 2024, indicated that the resident was on a scheduled toilet plan for bladder. Interventions included to offer assistance/encourage toileting at least every two hours during awake time and at bed checks. Offer toileting upon rising, within one hour before meals, within one hour after meals, at bedtime and whenever the resident requests. In addition to routine toileting, toilet at scheduled times as follows: have the resident sit on the toilet to void at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. if still awake. An interview with Resident 24 on August 27, 2025, at 10:47 a.m. revealed that she cannot use bathroom any sooner than every two hours and if she says she has to go, they don't always take her indicating that it is not her scheduled time to go. Interview with the resident's husband at the time of the resident interview indicated that they do not toilet her when needed. Review of Resident 24's clinical documentation from April 18, 2025, through August 22, 2025, including review of progress notes and review of the toileting program documentation, revealed that there was no documented evidence that the resident's toileting program was completed as scheduled and as per the resident's care plan. Interview with the Director of Nursing on August 30, 2025, at 12:50 p.m. confirmed that there was no documented evidence that Resident 24's toileting program was completed as scheduled and as per the resident's care plan. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 39 residents reviewed (Residents 7 and 9). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that the resident’s plan of care should be updated as necessary on an on-going basis. Changes will be communicated to team members as needed or indicated. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 7 dated August 4, 2025, indicated that the resident was cognitively intact, was understood, could understand, required assistance with daily care needs, and had diagnoses that included a stroke. Interview with Resident 7 on August 28, 2025, at 1:43 p.m. indicated that he currently had an indwelling catheter, and no other to have straight catheterization (single-use tube inserted into the bladder to drain urine). Physician’s order for Resident 7 dated August 11, 2025, indicated he had a indwelling foley catheter (a thin, flexible tube inserted into the urethra that carries urine from the bladder to the outside of the body to drain urine) size 16 French (Fr) with a 15 cubic centimeter (cc) balloon for urinary retention. The care plan for Resident 7 dated July 28, 2025, indicated that the resident was continent and incontinent of bladder. He has urinary retention with the need for intermittent catheterization. Resident 7 has a intervention that he requires straight catheterization. An interview with the Assistant Director of Nursing on August 28, 2025, confirmed that Resident 7 care plan was not revised to reflect that he has an indwelling catheter and should have been. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 9 dated June 25, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included a hip fracture. The Care plan for Resident 9 dated June 24, 2025, indicated that the resident had anticoagulant (used to prevent and treat blood clots) medication ordered that included Lovenox (an anticoagulant), and that the resident had diabetes and staff were to administer insulin as ordered. Review of the Medication Administration Record (MAR) for Resident 9 dated August 2025 and September 2025, revealed no documented evidence that the resident received Lovenox or insulin. An interview with the Director of Nursing on August 30, 2025, confirmed that Resident 9 was no longer receiving Lovenox or insulin and her care plan should have been revised to indicate that. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 39 residents reviewed who used a electric lifting recliner chair (Resident 6) and failed to ensure that assistance devices to prevent accidents or injury were in place for one of 39 residents reviewed (Resident 15).Findings Include: A facility policy for wheelchair leg rests dated March 31, 2025, indicated that the facility would ensure and promoted safe and appropriate use of wheelchairs leg rests when transporting residents short or long distances. Wheelchair leg rests should be used when transporting residents over klong distances or when a resident is unable to lift their leg rests while the chair is in motion. Wheelchair leg rests should also be used when resident cannot or will not [NAME] their legs for short transports. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 10, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included chronic kidney disease (condition where the kidneys gradually lose their ability to function properly over time). A nurse’s note for Resident 6 dated August 7, 2025, at 4:41 a.m. revealed that the resident was observed on his knees facing his recliner with his upper body resting on the recliner. The resident reported at the time that he was getting up to ring his call bell. An occupational therapy note for Resident 6 dated August 13, 2025, indicated that the resident was able to operate his recliner to sit upright and elevated with supervision. Observation in Resident 6’s room on August 27, 2025, revealed the resident sitting in his wheelchair with a electric lifting recliner chair in his room in the up position. Review of a fall investigation provided by the facility dated August 7, 2025, indicated that the Resident 6 was in his recliner because he was vomiting earlier in the night and that he has poor safety awareness with impulsive actions and behaviors. An interview with the Director of Nursing on August 29, 2025, at 2:02 p.m. revealed that the facility did not have an electric lifting recliner chair safety assessment completed on Residents 6 who used electric lifting recliner chair at the time of the survey. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 15 dated July 31, 2025, indicated that the resident was severely cognitively impaired, was usually understood, could usually understand, required assistance with daily care needs, used a wheelchair for mobility, and had diagnoses that included a rheumatoid (Joint pain, stiffness and swelling) and osteoarthritis Joint pain, stiffness, creaking or grinding sounds in the joints, and limited range of motion) Observations on August 27, 2025 at 11:46 a.m. revealed that Hospitality Aide E5 pushed Resident 15 from the her room to in the dining room through the hall past both nursing stations while her feet, which had shoes were crossed at the ankles, with one foot dragging on the floor. Interview with Hospitality Aide E5 on August 27, 2025 at 11:31 a.m. revealed that she pushed the resident to the dining room for lunch. She stated that Resident 15 was able to self-propel and that is why she did not have leg rests on her chair. She further stated that she didn't think that she had foot petals for her wheelchair. Interview with Director of Nursing on August 28, 2025, at 9:44 a.m. confirmed that Resident 15 should have had leg rests on her wheelchair while being transported if she was unable to lift her feet off the floor. She said that they will use them for long distances when outside of the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for two of 39 residents reviewed (Residents 10 and 88). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that it is the facility’s policy that each resident receives individualized, comprehensive, and coordinated care through the development, implementation and ongoing evaluation of an interdisciplinary care plan. The development of a comprehensive care plan should occur by the interdisciplinary team following the initial Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 17, 2025, revealed that the resident was cognitively impaired, was usually understood and was able to sometimes understand others, required assistance with care needs, took an anticoagulant medication (used to prevent or treat blood clots). Physician’s orders for Resident 10, dated August 25, 2025, included an order for the resident to receive 2 milligrams (mg) of warfarin (an anticoagulant) every other day for atrial fibrillation (irregular heart rhythm). There was no documented evidence that the facility implemented a care plan related to the resident’s need for anticoagulant therapy. An interview with the Director of Nursing on August 30, 2025, at 2:37 p.m. confirmed that there was no documented evidence that the facility implemented a care plan related to Resident 10’s need for anticoagulant therapy. A quarterly MDS) assessment for Resident 88, dated July 11, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included heart failure and was receiving anticoagulant medication (used to prevent or treat blood clots). Physician’s orders for Resident 88 dated August 27, 2025, included for the resident to receive 3 milligrams (mg) of warfarin (an anticoagulant) daily. An interview with the Assistant Director of Nursing on August 30, 2025, at 1:11 p.m. confirmed that Resident 88's care plan did not include care and treatment needs related to the resident’s anticoagulant medication use. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the person's mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 39 residents reviewed (Residents 3 and 36).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was admitted to the facility on [DATE], was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards others, took antipsychotic medications (medications used to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications (psychotic medications), and had diagnoses that included Alzheimer's dementia, depression, and anxiety.Physician's orders for Resident 3, dated May 13, 2025, May 30, 2025, and August 1, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan (a psychotropic medication) gel twice daily as needed for agitation. A psychiatry note for Resident 3, dated May 23, 2025, revealed that as needed Ativan gel was recently added May 15, 2025, by the resident's primary care physician.Review of Resident 3's Medication Administration Record (MAR) for May 2025 through August 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., June 24 at 3:54 p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., July 7 at 3:35 a.m., August 16 at 8:00 p.m. and August 25 at 3:26 a.m.Review of Resident 3's clinical record revealed no documented evidence that an informed consent was obtained from the resident representative prior to initiating the administration of the as needed transdermal Ativan.An admission MDS assessment for Resident 36, dated August 25, 2025, revealed that the resident was cognitively impaired, was rarely/never, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer's dementia and anxiety.Physician's orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive 0.25 mg of Ativan three times daily as needed for anxiety and agitation.Review of Resident 36's MAR for August 2025, revealed that the resident received 0.25 mg of Ativan on August 23 at 1:17 p.m., August 25 at 3:32 p.m., and August 27 at 8:39 p.m.Physician's orders for Resident 36, dated August 25, 2025, revealed that the resident was to receive 0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for anxiety/agitation.Review of Resident 36's MAR for August 2025, revealed that the resident received 0.25 mg of transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29 at 12:30 p.m.Review of Resident 36's clinical record revealed no documented evidence that an informed consent was obtained from the resident representative prior to initiating the administration of the as needed Ativan.Interview with the Director of Nursing on August 29, 2025, at 2:02 p.m., revealed that the facility was completing informed consents for use of antipsychotic medications, but not for any other psychotropic medications.28 Pa. Code 201.29(a)(j) Resident Rights.

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 83). Findings include: Review of Resident 83's clinical record revealed that the resident was discharged from the facility on July 2, 2024. Further review of Resident 83's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 10, 2024 at 10:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record

Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for one of four residents reviewed (Residents 2). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated March 2024, revealed EBP will be used in the care of any residents who are at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). Use of Enhanced Barrier Precautions is a strategy for improved success for infection control and to expand on standard precautions. Enhanced Barrier Precautions are designed to reduce the risk of transmission and/or colonization of MDROs from both recognized and unrecognized sources. Enhanced Barrier Precautions require gowns and gloves to be worn during any high-contact resident care based on the location of the organism (i.e., urine, nares, wounds, etc ). EBP are to be used for residents who are at an increased risk of infection, including those with a known infection or colonization of a resistant organism who do not require contact precautions, and residents with chronic wounds or indwelling medical devices. It is meant to remain in place for these residents during the duration of their stay at the facility. Isolation is not required for those who have EBP in place. Clinical records review revealed Resident 2 had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the coccyx. Observation conducted of Resident 2's room failed to reveal evidence of EBP signage/communication. Interview with the Director of Nursing, Nursing Home Administrator, and Wound Nurse was conducted on July 10, 2024, at 2:10 p.m., where it was confirmed that the EBP process was not followed for Resident 2. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and procedure, clinical record review and review of facility documentation, it was determined that the facility failed to ensure the safety of residents during a transfer for one of 24 residents reviewed (Resident 25). Findings include: Review of facility policy and procedure titled Safe Resident Handling revised February 2021 revealed mechanical lifting and transfer devices shall be inspected prior to use on every shift for the following, if applicable: emergency lowering capabilities, battery charge level adequacy, deformed or cracked components, missing bolts, missing safety latches, sling wear including fraying/heat damage, soiling/infection control concerns and free mobility of movement casters. Defective equipment shall be immediately tagged, removed from service and repaired prior to being put back into service. Mechanical lifting and transfer devices and other safe patient handling equipment will be maintained in a safe and sanitary condition at all times. Review of Resident 25's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible, progressive [CONDITION(S)] disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness, [CONDITION(S)] (joint inflammation) and difficulty walking. Review of Resident 25's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated April 29, 2021 revealed Resident 25 required the extensive assistance of two staff members for toilet use. Review of Resident 25's progress notes dated July 2, 2021 revealed Alerted by staff of resident's fall from Sara [mechanical lift] onto her right side while in her bathroom being transferred from toilet to w/c [wheelchair]. Review of witness statements dated July 2, 2021 revealed Upon inspection of the sling bottom waist strap buckle was missing a prong. This was not noticed when sling was applied. Review of employee statement dated July 9, 2021 and signed by employee revealed [employee] explained she did not inspect equipment prior to utilizing for transfer. 'We assumed it was in working condition.' Review of a second employee statement dated July 9, 2021 and signed by second employee revealed [employee] confirmed she did not inspect equipment prior to utilizing for transfer. She explained that she should have checked the lift sling. Interview with Director of Nursing on July 9, 2021 at approximately 11:00 a.m. confirmed that both employees failed to inspect the transfer equipment prior to use and further confirmed that this was against company policy and the failure of the equipment to be inspected resulted in Resident 25's fall from the transfer lift. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on a review of facility policy, observation, and resident and staff interviews, it was determined that the facility failed to serve food at the proper temperatures. Findings include: Review of the facility policy titled Safe Food Handling Practices with a revision date of October 10, 2011, revealed foods will be held within the safe temperature range throughout the receiving, storage, preparation, cooking and service process. Further review of the facility policy revealed in section Number two, which indicated Hot foods are to be held at 135 degrees or higher. Section Number three indicated Cold foods are to be held at 41 degrees or below. An interview on January 25, 2021, at 12:42 p.m. with Resident R6 revealed, Resident R6 does not want meal items that are served cooler than anticipated. I frequently get meals that are cold. I want my meals served hot not cold. Observation and examination of food at the point of service on a test tray conducted by dietary staff on January 25, 2021, at 12:45 p.m., revealed that the menu item, stuffed shells, registered at 125.9 degrees Farenheit (F), [NAME] vegetables registered at 107.7 F, mashed potatoes registered at 119 F, carrot cake with cream cheese icing registered at 64.5 F, and cranberry juice registered at 54.8 degrees F. None of the food items tested were at the proper serving temperature. The findings of the test tray were reviewed on January 25, 2021, at 1:10 p.m. with the Nursing Home Administrator and the Director of Nursing when the above information was presented. 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.29(j) Resident Rights

Based on observations, review of activity log and staff interview, it was determined that the facility failed to provide an activity program that met the needs and interests of all residents and in accordance with care planned interventions for three of three residents reviewed (Resident #28, # 67, and Resident #75). Findings Include: Observation on (MONTH) 1, 2019 approximately 1:20 p.m. to 2:30 p.m. of the Garden West unit revealed residents in living room with the television turned on or in their rooms resting. Further observation of Garden West unit (skilled nursing memory supportive unit) on (MONTH) 2, 2019 approximately 9:00-10:30 p.m. revealed residents in the living room observing television programming. Review of Resident #28's Quarterly MDS (minimum Data Set -periodic assessment of resident needs) dated (MONTH) 26, 2019 identified the resident with a BIMS (Brief interview of mental status) score of 5 which places the resident as cognitively impaired. Review of Resident #28's care plan, initiated (MONTH) (YEAR), revealed areas of interest identified for resident as one to one visits, crafts, cooking, entertainment, exercise, spiritual activities, and sensory stimulation activities. Review of Resident #28's activity logs from (MONTH) 1, 2019 to (MONTH) 30, 2019 revealed that the resident participated in watching television/newspaper twenty-two times in the month of (MONTH) 2019 and twenty times in the month of (MONTH) 2019. Further review of activity logs revealed resident attended bible study/hymn sing 11 times in the month of (MONTH) and 6 times in the month of (MONTH) 2019. Additional activities of Bingo/Movies/Music programs that resident attended were noted to be twelve times in (MONTH) 2019 and twenty-six times during the month of (MONTH) 2019. Further review of Resident #28's activity logs revealed that from (MONTH) 1, 2019 through (MONTH) 30, 2019 there were sixteen days without any documented activities. Review of Resident #67's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident's Admission MDS assessment dated (MONTH) 8, 2019 identified the resident with a BIMS (Brief interview of mental status) score of 3 which places the resident as cognitively impaired. Review of Resident #67's care plan goal for activities, initiated (MONTH) 2019, revealed activities of choice noted areas of interest as exercise, musical entertainment, spiritual programs, romance novels, and being off unit with supervision. Review of Resident #67's activity logs from (MONTH) 2019 through (MONTH) 2019 revealed eight days without activity participation or refusal from admission of (MONTH) 8, through (MONTH) 31, 2019 and nine days without activity participation or refusal from (MONTH) 1, through (MONTH) 30, 2019. Further review of Resident #67's activity logs revealed twelve times the only activity documented was Newspaper/Television during the month of (MONTH) and thirteen times during the month of (MONTH) 2019. Review of Resident #75's Quarterly MDS assessment dated (MONTH) 27, 2019 revealed in Section C (Cognitive Patterns) revealed resident is severely cognitively impaired. Review of Resident #75's activity care plan, initiated (MONTH) 2019, revealed activities of choice were entertainment, spiritual groups, live piano music, exercise, and volunteers for visits as tolerated/desired. Review of Resident #75's activity logs from (MONTH) 2019 through (MONTH) 31, 2019 revealed that there were nine days without any documented activity participation in (MONTH) 2019 and eight days in (MONTH) 2019 without any documented activity participation. Further review of Resident #75's activity logs revealed that for the month of (MONTH) 2019 there were twelve days that television/newspaper activity was identified as only documented activity and six times in (MONTH) 2019 that television/newspaper activity noted as only activity recorded. Interview on (MONTH) 3, 2019 at approximately 2:50 p.m. with the Nursing Home Administrator and non-licensed employee E3 when the above information was presented and indicated the activities were not representative of individual preferences or areas of interest. 28 Pa Code 201.29(j) Resident Rights 28 Pa Code 211.10(d) Resident care policies

Based upon review of facility policy and procedure and clinical record review, it was determined that the facility failed to ensure interventions were in place for the prevention of pressure ulcers for one of three pressure ulcers reviewed. (Resident #17) Findings include: Review of facility policy and procedure titled Skin Integrity - Preventative Care, revised (MONTH) 2019 revealed float heels for resident who are unable to reposition themselves; bed cradle/heel boots as necessary. Review of Resident #17's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident #17's Quarterly Minimum Data Set Assessment (MDS - periodic assessment of resident needs) dated (MONTH) 18, 2019 revealed a Brief Interview for Mental Status Score of 3 indicating severe cognitive impairment. Further review of Resident #17's Quarterly MDS revealed Resident #17 required the extensive assistance of two staff persons for bed mobility and transfer and indicated Resident #17 is at risk for pressure ulcer injury. Review of Resident #17's Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 12, 2019 revealed a score of 12 which indicated Resident #17 was at risk for pressure ulcer development. Review of Resident #17's (MONTH) 28, 2019 progress notes revealed Resident #17 was noted to have a fluid filled blister on the left heel. Review of Resident #17's Skin/Wound Tracking Report dated (MONTH) 29, 2019 revealed Resident #17 had a serous filled blister on the left heel which measured 3.0 centimeters (cm) x 4.0 c.m. Review of Resident #17's Skin Evaluation Form dated (MONTH) 29, 2019 revealed Resident with serous (blood tinged) filled blister on left heel which was documented on 4/28/19. Area assessed and intact serous filled blister noted on left inner heel. Area measures 3.0 x 4.0. Review of Resident #17's Skin Evaluation Form dated (MONTH) 6, 2019 revealed Serous filled blister on left heel now blood filled. Area will now be considered a DTI (deep tissue injury). Area measures 3.0 x 4.0. Resident denies pain to area. Surrounding skin very dry and blanchable. Resident is using heels off pillow to elevate and relieve pressure to b/l (bilateral) heels. Review of Resident #17's Skin Evaluation Form dated (MONTH) 13, 2019 revealed Left heel DTI now with dry stable eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed). Area measures 3.0 x 4.0. Area now considered unstageable. Review of Resident #17's active plan of care revealed the intervention of off-load heels when in bed was initiated on (MONTH) 29, 2019, one day after the wound was identified. Further review of Resident #17's active plan of care revealed that on (MONTH) 29, (YEAR) an intervention of instructing and encouraging resident to off-load heels was put into place. Further review of Resident #17's active plan of care failed to reveal that the resident's care plan was updated to reflect Resident #17's current cognitive status regarding the effectiveness of instruction or encouragement regarding the use of off-load heels and further failed to reveal any further interventions to prevent the development of pressure ulcers to the heels. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 4, 2019 at approximately 1:00 p.m. confirmed that the off-load heels intervention was not put into place until after the heel blister was discovered and further confirmed that no further interventions were in place to prevent the development of pressure ulcers to the resident's heels. 28 Pa. Code 211.5(f) Clinical Record 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to timely complete physician order [REDACTED].>Findings Include: Review of Resident 68's physician orders [REDACTED].), and a TSH ([MEDICAL CONDITION] stimulating Hormone- measures how much of this hormone is in your blood to determine [MEDICAL CONDITION] health). Review of the Lab results for Resident 68 revealed these labs ordered on (MONTH) 10, 2019 were not completed until (MONTH) 17, 2019. Further review of the labs revealed the resident had a Hemoglobin of 6.8 (red protein responsible for transporting oxygen in the blood, normal level is 13.5 to 17.5). Review of a nursing Progress note dated (MONTH) 17, 2019 at 5:20 p.m. states Supervisor made this nurse aware of Hemoglobin 6.8. Wife and Son updated. Son requested that resident be sent to the ER. Further review of the nursing progress notes revealed an entry on (MONTH) 17, 2019 at 11:02 p.m. stating Resident admitted with infection and low hemoglobin. Further review of resident 68's clinical record gave no clinical reason for completing the lab work one week after it was ordered by the physician. Interview with the Director of Nursing on (MONTH) 4, 2019 at 10:30 a.m. confirmed there was a delay in completing the physician order [REDACTED]. 28 PA Code: 211.5 (f) Clinical records 28 PA Code: 211.12 (d)(1)(5) Nursing services Previously cited 10/26/2019

Based on observation and review of facility policy, it was determined that the facility failed to ensure the safety of the residents by access to a country kitchen on one of three country kitchens. (First Floor) Findings include: Review of facility policy titled Kitchen Infection and Safety Inspections under subsection Unauthorized Traffic revealed item B which stated, In country kitchens, staff will ensure that front and rear doors remain in the locked position while staff is not present for safety and security if residents who may risk for wandering. Observation on (MONTH) 22, (YEAR) at approximately 7:33 p.m. during the initial tour of the country kitchen on first floor revealed the front door to the country kitchen was standing open, lock not engaged. Further observation of country kitchen and dining room on first floor revealed absence of staff in the immediate area surrounding the country kitchen and dining room. Observation on (MONTH) 22, (YEAR) at approximately 7:45 p.m. revealed an unsecured kitchen drawer with two long blade knives. There were no residents observed in the country kitchen and dining room at the time of this observation. The facility failed to ensure that the front door of the first floor country kitchen remain lock when no staff was attending the country kitchen. 28 PA Code 201.18 (b)(1) Management Previously cited 9/22/17 28 Pa. Code 201.29(a)(d) Resident Rights Previously cited 9/22/17 28 Pa. Code 211.12(d)(3)(5) Nursing Services Previously cited 9/22/17

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to assure the accountability and disposition of narcotic medication for one of three residents reviewed (Resident 99). Findings include: Review of facility policy for Medication Disposal and Returns, effective date (MONTH) 21, (YEAR), revealed that on the form Controlled Drug Receipt/Record Disposition Form, staff should complete the portion of the form entitled Disposition of Remaining Doses and two individuals shall witness and document the destruction of the medication. Review of Resident 99's physician's orders [REDACTED]. Review of medication documentation for the resident's [MEDICATION NAME] revealed that on (MONTH) 12, (YEAR), there were 27.625 milliliters of [MEDICATION NAME] left upon discharge. The documentation further revealed that the remaining doses were flushed, however; the disposition was only witnessed and signed by one licensed staff and not two licenses nurses. Interview with the Director of Nursing on (MONTH) 26, (YEAR), at approximately 11:30 a.m. confirmed that two licensed staff signatures were not documented as required for the disposition of a controlled drug. 28 PA Code 211.9(j) Pharmacy services Previously cited 9/22/2017 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 9/22/2017

Based on observation and review of facility policy, it was determined that the facility failed to maintain, and store food in a sanitary manner in the main kitchen. Findings include: Review of facility policy titled Safe Food Handling Practices under heading Procedures revealed for Number 15 Foods that have been opened, but not completely used, must have an open date indicated; and should be tightly sealed before storing. Observation on (MONTH) 22, (YEAR) at approximately 6:28 p.m. of the main kitchen during initial tour three packages of panini split top wheat rolls open but without an open date identified on package. Continue observation of kitchen revealed package of Harvest Pride hamburger buns that was open but did not have open date identified on package. Further observation of the kitchen noted two visibly soiled carafes with significant residue on inside of carafe on bottom shelf of a preparation table. Observation on (MONTH) 22, (YEAR) at 6:33 p.m. of the walk- in- freezer revealed packages of sandwich rye bread and hamburger buns that were open but without noted no open date. An open box of veal luncheon steaks chopped and formed but without an identified open date. A container of haddock fillets that was open but no identified open date. Also noted in the walk- in- freezer was two trays of cookies covered with saran wrap with an identified expiration date of (MONTH) (YEAR). Observation of walk in freezer #4 revealed unlabeled container of dough that did not have an open date nor identification of food contained in the box. Interview on (MONTH) 22, (YEAR) at approximately 7:05 p.m. with Director of Dining Services confirmed the containers of food which were open did not have identified open dates and carafes were visibly soiled. 28 Pa. Code 201.18 (b) (1) Management Previously cited on 09/22/17 28 Pa. Code 211.6 (c) Dietary Services Previously cited on 09/22/17

Based on observation, interview with facility staff, clinical record review, review of facility documentation, policies and procedures, dietary manuals and procedures for meal delivery and resident identification for special diets, it was determined that the facility failed to ensure that all residents with special dietary orders for consistency changes (mechanical soft or pureed diets or liquid consistency changes) were identified by nursing staff providing meal delivery resulting in one of one resident receiving the wrong foods causing actual harm to the resident (Resident R1) Findings include: Review of Resident R1 face sheet and physician orders [REDACTED]. thoracic spine). The [DATE] physician orders [REDACTED]. Review of the annual Minimum Data Set (MDS) assessment (Assessment of resident status and care needs) dated [DATE] included a care area assessment summary for nutrition status. The nutritional assessment care plan dated [DATE] indicated Resident R1 had increased risk of aspiration or choking during meals while providing nutrient dense foods. The care plan included approaches for safe swallowing. The dietary consistency level was a mechanically altered diet. The nutrition care plan also stated Resident R1's need for a mechanically altered diet for ease of chewing meats due to periodic lethargy and refusing to open mouth to eat at times. Review of the quarterly dietary notes dated [DATE] stated resident on Mechanical 1 diet. No adaptive equipment needed. Resident requires assistance with meals. Physician orders [REDACTED]. Occupational therapy progress notes dated [DATE] indicated occupational therapy was started and would continue for additional 90 days. Occupational therapy notes dated [DATE] recommended the use of a "Broda Chair" (a chair that provides support while sitting) on a trial bases. The notes stated the resident using the Broda Chair with instructions that he was to be in an upright position for meals, eating and functional tasks. Resident R1 ' s care plan dated [DATE] was updated to include occupational therapy and the trial use of the Broda Chair specifying that the resident be in the upright position for meals, eating and functional tasks. Offer tilts option for comfort. Review of the diet manual described a Mechanical Soft I diet as a regular diet that has been modified for ease of chewing and swallowing. All meats and equivalent foods are to be chopped. No whole meat items such as hot dogs, hamburgers, and other food items that are difficult to chew foods are to be provided. Review of the Summer Picnic Event flyer dated Thursday [DATE] stated residents who required mechanically altered or liquid altered diets were to wear stickers to identify their special diet restrictions. Review of facility reported event dated [DATE] stated that Resident R1 was outside for the annual community picnic. Residents that required texture altered diets (Pureed, Mechanical 1 or II, Thickened liquids diets wore stickers with symbols indicating the diet restrictions at the picnic. The symbol for mechanically altered diets was a covered wagon. Staffs were aware of the symbol codes. The resident was sitting at a table with other residents and 3 CNA ' s (certified nursing assistants). Resident R1 required supervision but was able to feed himself. The resident was upright in a Broda Chair. The Mechanical soft covered wagon symbol was found later under the resident ' s chair. At approximately 1:15 p.m. the DON who was sitting at a table next to resident, was called by CNA since resident appeared to be choking. Resident slumped forward. Heimlich attempted with no food expelled. Resident assisted to feet and Heimlich attempted again with no success. Resident was taken into facility and placed in bed with oxygen. Resident had DNR order (do not resuscitate). Physician and POA and 911 called. EMT suctioned resident and removed a piece of hot dog. CPR began POA/ resident ' s son waivered on decision to continue CPR. Resident ' s daughter/other POA came and CPR stopped per son and daughter ' s request. Coroner arrived and pronounced resident ' s death was accidental related to aspiration of food bolus. Parkinson ' s disease was a contributing factor. Documentation stated that Resident R1 was sitting at a table with 3 other residents and 3 certified nursing assistants (CNA's). "One CNA went up to obtain desserts. The resident was able to feed self per care plan, required supervision, cueing and assistance at time. The resident was in a Broda Chair in the correct upright position. A Mechanical Soft I diet sticker was found later under his chair. At 1:15p.m. the licensed nurse who was at another table was called by the CNA to check resident as he appeared to be choking. Resident was observed slightly slumped forward and had difficulty with airway exchange. Nails were slightly blue, face pale. Attempted Heimlich in chair with no food expelled, several staff assisted resident to his feet, Heimlich attempted again by multiple staff members with no success. Resident taken into building, oxygen initiated and suctioned several times with mucus and small amount of yellow liquid obtained. Airway exchange did improve. Resident had order for DNR (Do Not Resuscitate). Physician, POA and 911 called. 911 arrived within approximately 5 minutes. EMT suctioned resident and removed a piece of hot dog then attempted intubation (placing a breathing tube into lungs) and began CPR. The Resident's son/POA waivered on the decision to continue CPR. Sister also POA was called and arrived within minutes. CPR stopped per their request. Coroner arrived. Resident ceased to breath." Review of nurses ' note dated [DATE] at 3:30 p.m. related that the resident was blue and not breathing. DON attempted the Heimlich while resident was still in Broda Chair. Resident was removed from chair and stood by several staff and DON and staff educator attempted again the Heimlich. CNA also attempted. No object ejected from mouth. Resident transported via wheelchair into facility. Suction was attempted without success. Oxygen applies. EMT arrived and placed resident onto stretcher and attempted to intubate resident. EMT attempted to suction resident and able to remove a piece of hot dog. EMT completed intubation and CVPR started until family requested CPR to be stopped. Interview with the Director of Nursing on [DATE] between 9:45 a.m. and 1:00 p.m. confirmed the above. The DON stated the certified nursing assistant CNA Employee #2 call her and said the resident was choking at 1:15 p.m. Resident R1 could not speak. The DON first tried several back blows with the resident leaning forward but no food was expelled. Abdominal thrust were tried while resident was in the chair and then standing up. No food was expelled but seemed to have improved air exchange. Review of another nurse ' s note dated [DATE] stated that 911 arrived at approximately at 1:20 p.m. The deputy coroner was present and pronounced the death. The death certificate stated Resident R1 died [DATE] due to aspiration of food bolus at 2:56 p.m. Parkinson's disease a contributing factor and the manner of death was accidental. Interview with the DON on [DATE] confirmed that the reason why staff did not place Resident R1 on the ground was due to his [DIAGNOSES REDACTED].) This prevented the resident from being able to lie flat. It was noted that the EMT's moved the resident to their stretcher but they could not leave him in the flat position. Interview with CNA Employee E2 on [DATE] between 2:30 p.m. and 3:00 p.m. revealed that he was across the table from Resident R1 helping another resident when he heard something and looked at Resident R1 and realized he was choking. He did yell for the Director of Nursing and they did try back blows and abdominal thrusts without success. CNA Employee E2 confirmed the Broda Chair was in the upright position. Staff was able to stand the resident and perform abdominal thrust but they were not successful. When asked how much the resident had eaten at lunch CNA Employee 2 stated " not very much. " . Interview with the DON on [DATE] between 11:45 a.m. - 12:45 p.m. .related that although certified nursing assistants knew the special diet symbol codes on the stickers used to identify residents ordered mechanically altered diets at the picnic, there was no other measure put into place to ensure that CNA ' s could use to check the diet orders for residents. A covered wagon sticker with an M1 was the symbol for Resident R1, mechanically altered 1 diet order. The DON stated the sticker was not on the resident ' s shirt. At the picnic only residents on modified consistency diets wore stickers (mechanical soft, pureed or thickened liquid diets). There was no methodv for CNA's serving residents foods at the picnic to verify the diet order for any resident at the picnic ( Residents with and without stickers). Interview with the DON on [DATE] at this time stated that at the picnic, certified nursing assistants went to the dietary server and obtained food for the residents that was set up at the serving area. Interview with CNA Employee E3 on [DATE] between 3:00 and 3:30 p.m. stated that she did not see a covered wagon M1 sticker on Resident R1. CNA Employee E3 stated she obtained the regular hot dog and bun from the dietary server and gave it to Resident R1 CNA Employee E3 admitted that she thought Resident R1 was on a mechanical soft 1 diet but did not have a sticker on his clothing to identify him as needing a special diet. CNA Employee E3 went on to say that she had not worked with Resident R1 for a while and figured that the "hot dog was soft". CNA Employee 3 served the resident food but did not assist him and did not witness him starting to choke. Interview with the DON on [DATE] at this time confirmed that the dietary staff and licensed nurses are trained to know diet modifications based on diet orders but that certified nursing assistants do not receive training on diet modifications based on diet orders. During the interview with CNA Employee E3 on [DATE] between 3:00 -3:30 p.m., the employee acknowledged that she obtained a hot dog and bun for Resident R1 from the dietary servers and did not see a covered wagon sicker M1 on Resident R1 ' s clothing (symbol for mechanical soft 1 diet order) . The hot dog was not cut up. CNA Employee E3 was asked about how much Resident R1 ate she stated only one bite of hot dog because the bun hadn't been touched and hardly anything on the plate. CNA Employee E3 acknowledged that she should have asked to be sure that his diet was right. When asked how the Broda Chair was positioned she agreed that the chair was in the upright position. When nursing Employee E3 was asked about how they, the CNA's, are informed of the resident special diet modifications, CNA Employee 3 stated they are not directly told, usually discovered when they go to document in the Care Tracker System. The facility failed to ensure that CNA staff who serve residents foods are knowledgeable in the diet modification needs of the residents and failed to ensure that special diet orders were verified before giving residents foods. This resulted in Resident R1 receiving the wrong food leading to his choking and resulting in his accidental death. 28 PA Code: 201.14(a) Responsibility of licensee 28 PA. Code: 201.18(a)(b)(1)(3)(e)(1) Management 28 PA. Code: 201.20(a) Staff development 28 PA Code 211.10(a) Resident care policies 211.12(c)(d)(1) Nursing services 211.12(3)(5) Nursing services Previously cited [DATE]