Every finding on record at Quincy Retirement Community

Based on clinical record review and staff interview, it was determined the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman for one of one residents reviewed for hospitalization (Resident 55).Findings Include: Review of Resident 55's clinical record revealed diagnoses that included metabolic encephalopathy (acute brain dysfunction caused by systemic illness) and sequelae of cerebral infarction (physical, cognitive, and psychological disabilities resulting from brain tissue damage). Further review of Resident 55's clinical record revealed that on December 26, 2025, and January 1, 2026, Resident 55 was transferred out of the facility to the hospital and was subsequently admitted to the hospital. Review of the facility's Ombudsman transfer/discharge reporting documentation for the months of December 2025 and January 2026 revealed that Resident 55 was not on the list for either month. During an interview on February 25, 2026, at 12:09 PM, with the Nursing Home Administrator (NHA), it was confirmed that Resident 55 was not on the list for December 2025 and January 2026. The NHA stated that there had been a change in computer programs and residents that had elected to be a bed-hold were not generating on the transfer/discharge list. The NHA also stated that they were working on fixing the issue and that it was the expectation of the facility that transfers/discharges be accurately reported to the ombudsman's office. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(3) Management

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 59).Findings include: Review of facility policy, titled Wound Care, dated December 29, 2025, revealed, in part, Health Center Registered nurse will assess, document, and notify the physician of a new pressure injury no later than the end of the following shift from the time the wound is found. Consult the dietician for all residents at risk for or with skin breakdown or wounds. Nutritional goals should be established. In addition, the policy indicated black heels that are intact and without signs and symptoms of infection or fluctuation are treated with pressure redistribution. No dressing is necessary. Float heels. May apply protective barrier twice a day and as needed. Review of Resident 59's clinical record revealed diagnoses that included unstageable pressure ulcer of left heel (an ulcer that has full thickness tissue loss in which the base of the wound is covered by slough [yellow, tan, gray green, or brown] and/or eschar [tan, brown, or black]), Alzheimer's Disease (a progressive mental deterioration due to generalized degeneration of the brain, characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability), and Type II Diabetes (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not usually require the use of insulin) with polyneuropathy (a condition in which multiple nerves are damaged leading to weakness, numbness, and impaired function in various parts of the body). Review of Resident 59's skin check form dated August 19, 2025, at 3:19 PM, created by Employee 1 (Licensed Practical Nurse) and revised by Employee 2 (Registered Nurse), indicated that a new pressure ulcer had been identified on Resident 59's left heel. In the clinical suggestions section of the form, suggestion 1. If new onset or worsening, notify provider was not marked. Review of Resident 59's progress notes revealed a corresponding skin check progress note dated August 19, 2025, at 3:19 PM, written by Employee 2, which indicated Resident 59 had a new in-house acquired skin issue to her left posterior heel identified as an unstageable pressure ulcer/injury due to dry scabbed area. The wound measured 1 centimeter (cm) long by 1 cm wide by 0 cm deep, and the surrounding skin was normal in color and temperature and had no swelling noted. The note indicated that the area was cleansed with povidone iodine and no dressing applied. The note further indicated that Resident 59's shoes appeared too small, shoes removed, slipper socks in place to prevent further irritation.will offload pressure. The note failed to reveal that Resident 59's physician was made aware of the new pressure ulcer. Review of Resident 59's progress notes revealed an orders administration note dated August 22, 2025, at 2:58 PM, written by Employee 1, that indicated that Resident 59's weekly skin evaluation was not completed as ordered and that Employee 1 was unable to complete due to time. Review of Resident 59's skin check form dated August 29, 2025, at 11:56 AM, created by Employee 3 (Licensed Practical Nurse) indicated that Resident 59 was noted to have a new unstageable pressure ulcer/injury to her left heel. In the clinical suggestions section of the form, suggestion 1. If new onset or worsening, notify provider was not marked. Review of Resident 59's progress notes revealed a corresponding skin check progress note dated August 29, 2025, at 11:55 AM, written by Employee 3 (Licensed Practical Nurse) that indicated Resident 59 had a new in-house acquired skin issue to her left posterior heel identified as an unstageable pressure ulcer/injury. The wound measured 1 cm long by 1 cm wide by 0 cm deep and was dry and intact with 100% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab-like) noted. The note failed to reveal that Resident 59's physician was made aware of the new pressure ulcer. Review of Resident 59's progress notes revealed a progress note dated September 4, 2025, at 4:50 PM, written by Employee 4 (Registered Nurse) that indicated Resident 59 complained of discomfort to her left heel after a recent fall. The note further indicated that upon assessment, after the fall, Resident 59 was noted to have an open wound measuring 1.5 cm long by 1.5 cm wide with a pink moist center on her left heel. The note further indicated that the area was cleansed, collagen was applied and was covered with a silicone dressing. Review of Resident 59's fall incident report dated September 4, 2025, at 4:45 PM, revealed that her physician was made aware of the fall and resulting in an open wound to her left heel. Review of Resident 59's physician order history confirmed that a treatment order for her left heel pressure ulcer was obtained from her physician on September 4, 2025. Review of Resident 59's progress notes revealed a nutrition dietary note dated October 13, 2025, at 12:08 PM, written by Employee 5 (Dietician) that indicated Resident 59 was noted to have an unstageable pressure injury to her left heel based on Resident 59's October 9, 2025, skin check. The note further indicated that Employee 5 made recommendation to add a protein supplement to promote wound healing. Further review of Resident 59's clinical record failed to reveal any documentation that nursing staff had notified the facility dietician of Resident 59's pressure ulcer/injury between August 19, 2025, and October 13, 2025. During a staff interview with the Nursing Home Administrator on February 25, 2026, at 2:02 PM, she confirmed that nursing staff should have notified Resident 59's physician and the dietician at the time that Resident 59's left heel pressure ulcer was identified. In addition, she confirmed that on August 19, 2025, Employee 2 applied a treatment that was not ordered by Resident 59's physician or part of the physician approved facility wound protocols. 28 Pa. Code 201.14(a) Responsibility of licensee.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 facility policy review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure alleged violations involving abuse were investigated thoroughly and reported in a timely manner for one resident reviewed for abuse allegation (Residents 1).Findings include: Review of facility policy, titled Abuse, Neglect, Exploitation last reviewed December 25, 2025, revealed Under the Elder Justice Act, an individual must report any reasonable suspicion of a crime against a resident or participant within 2 hours of the reasonable suspicion if the incident involves serious bodily injury and within 24 hours if the incident does not involve serious bodily injury. The facility policy added a section, titled Identification of Abuse, that stated:All bruises, skin tears and other found injuries are investigated for potential abuse.Event and Response Reports are reviewed by physician, Director of Nursing, MedicalDirector, and Administrator for further action.Review of the facility incident dated December 24, 2025, at 9:00 PM, stated NA (Nursing Assistant) reported [Resident 1] had a bruise on left forearm. Upon assessment resident was found to have a 10 cm (centimeter) x 6 cm red/purple colored bruise on left forearm near the elbow. Some swelling noted. The writer of the incident also added that the Resident was asked if she knew how it happened, and the Resident stated, him. The Resident did not elaborate how it happened, but did say she doesn't want him to ever touch her again. The only person notified based on the incident report was the daughter of Resident 1. The daughter was notified on December 24, 2025, at 10:20 PM. A review of the form titled, Interview/Statement Form for Investigative Purposes, was completed by Employee 3 (NA) who was providing care to Resident 1 on December 24, 2025. This statement was obtained on December 24, 2025, at 10:00 PM. Employee 3 (NA) documented that he noticed a mark on Resident 1 while getting her ready for bed. While getting resident ready for bed halfway through she started tossing and turning and when I sat her back into chair I noticed the mark. There was not further investigation into the abuse allegation. Review of facility's interview dated December 26, 2025, two days after the allegation, a statement obtained from Employee 3 regarding the events of December 24, 2025, during care of Resident 1. On last rounds on 3-11 shift I saw resident becoming anxious and normally that means she needs changed. So I got her in bed and started to change her and I had removed her brief and after that she became restless and agitated and started tossing and turning not allowing me to change her. After a few moments I got her changed and put back into her chair when I noticed the bruise on her arm and reported it to the nurse. Prior to changing her she had been wheeling herself all around the unit as well as exit seeking. While she was roaming she was pulling herself by the wall. Review of facility's interview on December 26, 2025, with Employee 1 (NA) provided a statement while providing care to [Resident 1] this morning I noticed a large dark bruise. Unaware of it on 12/25 she had long sleeves on and went LOA (leave of absence) with family at noon. Review of facility's interview on December 26, 2025, with Employee 4 (Licensed Practical Nurse) stated, I worked 12/24/25 7-3 PM. I did not notice bruise to [Resident 1's] left forearm. No incident reported to this writer on 12/24/2025. I did not work 12/25/25. Incident not reported to this writer. [Resident 1] informed this writer and NA on 12/26/2025, at 10 AM that the 'Big fat white guy was rough with her yesterday and mean to her.' On December 26, 2025, the Nursing Home Administrator (NHA) filed a Community Grievance Form documenting that Resident 1 was upset with a male caregiver from 12/24/2026. During an interview with the NHA on January 28, 2026, at 3:00 PM, the NHA said that a grievance form was completed December 26, 2025, Administration decided the incident should not be reported as abuse. The NHA added that no other residents complained about Employee 3's care when questioned on December 26, 2025. When asked about Employee 3's working status, the NHA stated that he worked 3:00 PM until 3:00 AM on December 24, 2025, and has no longer been utilized by the facility. When asked if the provider was notified on December 24, 2025, the NHA was unable to determine if he was notified. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, employee file review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision and assistance devices to prevent accidents, which resulted in harm as evidenced by a fall and fractured nose for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled Falls Management Program, dated December 29, 2025, revealed, in part, The facility will ensure the resident environment remains as free of accident hazards as possible. [Facility] is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing each resident with adequate supervision and assistance devices and functional programs as appropriate to prevent accidents. Review of facility policy, titled Wheelchair Mobility Policy, dated December 30, 2025, revealed, in part, Residents who use wheelchairs shall do so in a manner that promotes safety, dignity, and independence while preventing injury. Wheelchair mobility may be self-propelled by the resident or assisted by staff, based on the resident's needs. Foot pedals/footrests must be properly positioned and in place prior to staff assisting with wheelchair propulsion, unless clinically contraindicated and documented in the resident's plan of care. Review of Resident 1's clinical record revealed diagnoses that included history of falling, muscle weakness, acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 1's clinical record progress notes revealed that he had a witnessed fall on December 28, 2025, at 12:45 PM. The nurse's note dated December 28, 2025, at 3:28 PM, indicated that the Resident was lying on the floor in the hallway outside the dining room on his left side. Other staff were noted to be with the Resident. The note indicated that Resident 1 was alert per his normal status and answered questions appropriately. Resident 1 was noted to have an abrasion to his forehead, and his nose was swollen and deviated to the right with no bleeding noted. Resident 1 denied pain. Neurological checks were initiated and were noted to be within normal limits. Resident 1 was noted to be able to move his arms and legs per his norm with no complaints or abnormalities noted. Resident 1 was assisted into his wheelchair with no issues or complaints. Resident 1's provider was notified, and an order was given to obtain facial x-rays and to continue neurological checks per the facility protocol. Resident 1's Responsible Party was notified of the fall, injuries, and new orders. Review of Resident 1's x-ray reports dated December 28, 2025, revealed an acute and depressed fracture of the distal third aspect of the bridge of the nose. Review of Employee 1's (Nurse Aide) witness statement regarding Resident 1's fall dated December 28, 2025, indicated Resident 1 was rolling out of dining room. His feet got tangled up and he fell. Review of Employee 2's (Nurse Aide) witness statement regarding Resident 1's fall dated December 28, 2025, indicated that Resident 1 was sitting in front of the dining room doorway and that when Employee 1 pushed his chair to move him to get other residents through his foot got caught in the wheel and he fell out of the chair. The witness statement also indicated that Resident 1 does not wear leg rests because he self-propels throughout the day. Review of Employee 3's (Licensed Practical Nurse) witness statement indicated that Employee 4 (Registered Nurse) spoke to Employee 3 on December 28, 2025, at the time of Resident 1's fall. The statement indicated that Employee 3 reported he was on the medication cart passing medications when he looked down the hallway toward the dining room and observed Employees 1 and 2 assisting residents out of the dining room. Employee further indicated that he saw Employee 1 pushing Resident 1 in his wheelchair when his foot became caught, causing Resident 1 to fall forward out of the wheelchair onto the floor. Employee 3 further reported that Employee 2 was standing nearby and appeared to be attempting to alert Employee 1 as he heard Employee 2 call out immediately right before the fall but confirmed that he was unable to clearly hear what was said by Employee 2. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on January 12, 2025, at 10:00 AM, the NHA indicated that they immediately began the investigation into potential neglect and implemented an immediate plan to prevent the same scenario from recurring. The NHA confirmed that Resident 1 typically self-propelled through the facility in his wheelchair using his feet, so no leg rests were on the wheelchair. Review of the facility's immediate plan of correction, revealed the following:1) Resident [1] assessed immediately by Registered Nurse on December 28, 2025, after fall, and treatment orders obtained. Fall incident investigation initiated and on December 29, 2025 was reported to the Department of Health, state police, area Office on Aging, Department of Aging. Alleged perpetrator placed on administrative leave pending investigation outcome.2) The Assistant Director of Nursing or designee will conduct an audit of current residents who utilize a wheelchair for mobility to ensure that each chair has a designated set of leg rests present for use. Audit will be completed by December 30, 2025. Any discrepancies will be addressed. 3) The Assistant Director of Nursing or designee will provide re-education to current healthcare staff on the requirement to utilize foot pedals/ leg rests when assisting wheelchair propulsion and education on the policy for Wheelchair Mobility. Staff education will be completed by January 1, 2026.4) The Nursing Home Administrator or designee will conduct ongoing audits three times weekly for four weeks then three times monthly for two months to ensure that chairs have footrests and observe staff providing wheelchair propulsion for residents to ensure adherence to the Wheelchair Mobility Policy. These audits will be forwarded to the Quality Assurance Performance Improvement Committee for review and recommendations.5) Date of compliance: January 1, 2026. Review of facility plan of correction revealed that the house-wide audit was completed by the Assistant Director of Nursing on December 30, 2025, education was completed by January 1, 2026 and ongoing audits were initiated and continue. Staff interviews with Employees 6 (Nurse Aide), 7 (Licensed Practical Nurse), 8 (Nurse Aide), and 9 (Nurse Aide) on January 12, 2026, indicated they had recently received training regarding the use of leg rests when staff are propelling a resident in their wheelchair. Random tours of the facility completed on January 12, 2026, between 9:35 AM and 11:30 AM, failed to reveal any staff propelling residents in wheelchairs without the presence of leg rests. During a final interview with the NHA on January 12, 2025, at 12:00 PM, she indicated that Employee 1 should have applied leg rests if she was going to be moving or transporting Resident 1 in his wheelchair. The NHA further indicated that the nurse aide denied moving the wheelchair, even though two other staff members indicated in their statement that they observed this occurring. The NHA indicated that she believes Employee 1 did not intend to harm the Resident, but that she failed to identify all the potential safety hazards, which resulted in the unfortunate accident. Employee 1 was terminated on January 2, 2026. During an onsite survey on January 12, 2025, resident records were reviewed, staff were interviewed, and observations were conducted which revealed no concerns with resident safety. 201.14(a) Responsibility of licensee.201.18(b)(1) Management.201.20(a)(1) Staff development.211.10(d) Resident care policies.211.12(d)(1)(2)(3) Nursing services.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that residents' medical records were complete and accurately documented for one of 18 residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included fracture of the left ulna (break of the bone in the forearm) and anxiety disorder (excessive and persistent worrying). Review of Resident 5's January TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed the following order was not documented as being completed on the dates noted: splint - three times a day, ensure left arm splint on left arm at all times; not documented day shift January 28 and 29, 2025; evening shift January 25, 30, and 31, 2025; and night shift January 23, 24, and 31, 2025, and February 5, 2025. During an interview with Resident 5 on February 4, 2025 at 10:41 AM, it was revealed she wears the brace at all times since having her cast removed about two weeks ago. Email correspondence with the Nursing Home Administrator (NHA) on February 6, 2025, at 3:38 PM, revealed the facility had no additional information to provide in regard to the missing documentation. The NHA stated it was the expectation of the facility that documentation be completed accurately. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on staff interview and record review, it was determined that the facility failed to develop a comprehensive care plan that included a history of urinary tract infections (UTI's) for one of 21 records reviewed (Resident 43). Findings include: A review of the clinical record for Resident 43 revealed diagnoses that included history of UTI's and Non-Alzheimer's Dementia (a group of cognitive disorders that cause memory loss, confusion, and other symptoms observed with Alzheimer's disease but have different underlying causes). A review of the clinical record for Resident 43 revealed admission to the facility on [DATE]. Resident 43 was admitted with a diagnoses of UTI. Resident 43 was ordered Macrobid (antibiotic) 100 mg (milligram) for 10 days. The clinical record also revealed that Resident 43 had a UTI on February 9, 2024. Resident 43's Urologist (a doctor who specializes in the urinary tract system) ordered Nitrofurantoin MCR (antibiotic) 50 mg capsule by mouth daily as a preventive measure due to a history of UTI's. A review of Resident 43's care plan failed to reveal a care plan with a focus on UTI's. During an interview with the Nursing Home Administrator (NHA) on February 5, 2025, at 11:00 AM, the NHA confirmed the comprehensive care plan with a focus on UTI's should have been developed for Resident 43. 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 21 residents reviewed (Residents 1, 13, and 64). Findings include: Review of Resident 1's November 2024 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an ongoing order for Olanzapine (antipsychotic medication) twice daily, effective September 14, 2024. Review of Resident 1's December 26, 2024, quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that this assessment was not coded to indicate that she had received antipsychotic medications since admission/entry, reentry, or the prior OBRA assessment (Omnibus Budget Reconciliation Act - set federal standards for nursing home care), whichever was more recent. Review of Resident 1's MDS assessment completion and submission schedule revealed that a comprehensive OBRA assessment was completed on October 28, 2024. In an email received from the Nursing Home Administrator (NHA) on February 6, 2025, at 10:32 AM, she acknowledged that the aforementioned MDS assessment was coded incorrectly and provided a corrected version. Review of a physician encounter report dated September 24, 2024, revealed that Resident 13 had an active colostomy (surgical procedure that bypasses part of the colon and redirects feces to come out of a new hole in the abdomen). Review of Resident 13's September 2024 TAR (Treatment Administration Record) revealed orders for colostomy care every shift, effective September 11, 2024. Review of Resident 13's September 25, 2024, quarterly MDS revealed that it was not coded to indicate that Resident 13 had an ostomy (including colostomy). In email correspondence received from the NHA on February 7, 2025, at 9:27 AM, she revealed that presence of Resident 13's colostomy should have been noted on the aforementioned MDS assessment. During an interview with Resident 64 on February 3, 2025, at 11:02 AM, she revealed that she was receiving wound care for an open area on her left heel. Review of wound consult report dated December 5, 2024, revealed that the wound on Resident 64's left heel was reclassified as a diabetic ulcer (slow healing wounds that develop due to nerve damage, poor circulation, or injury in people with diabetes) associated with type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Review of Resident 64's December 17, 2024, quarterly assessment revealed it was not coded to indicate that Resident 64 had a diabetic ulcer. In an email received from the NHA on February 7, 2025, at 9:27 AM, she confirmed that MDS errors existed and would be addressed. 28 Pa. Code 211.12(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the resident care plan was not reviewed and revised to reflect the resident's current status for one of 21 residents reviewed (Resident 10). Findings include: Review of Resident 10's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream) and stage 3 chronic kidney disease (moderate loss of kidney function). Review of Resident 10's active care plan on February 4, 2024, at 1:00 PM, revealed that she was careplanned for having an indwelling catheter (device inserted into the bladder for drainage). Review of hospital notes dated October 26, 2024, revealed that Resident 10's foley catheter was removed on that date. Observation of Resident 10 on February 4, 2025, at 9:37 AM, failed to reveal the presence of a catheter. Review of Resident 10's February 2025 MAR and TAR (Medication and Treatment Records) failed to reveal any orders for an indwelling catheter. In email correspondence received from the Nursing Home Administrator on February 7, 2025, at 9:27 AM, she confirmed that a care plan issue existed. Review of Resident 10's care plan on February 7, 2025, at 9:00 AM, revealed that it had been updated and information regarding Resident 10 having an indwelling catheter had been removed. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for five of 18 residents reviewed (Residents 8, 19, 49, 56, and 76). Findings include: Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Further review of Resident 8's clinical record revealed their admission progress note dated January 2, 2024, which indicated the presence of an unstageable deep tissue injury. Review of Resident 8's Comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of January 8, 2024, revealed in Section M. Skin Conditions at question 0300, that they had an unhealed pressure ulcer staged as an unstageable deep tissue injury that was not present upon admission. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 6, 2024, at 11:50 AM, the aforementioned coding concern was shared for follow-up. Email communication received from NHA on March 6, 2024, at 2:01 PM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. She also indicated that she would expect the MDS to be completed accurately. Review of Resident 19's clinical record revealed diagnoses that included ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area) and diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 19's Quarterly MDS with the assessment reference date of February 12, 2024, revealed in Section N. Medications at question N0350, that they had received insulin (a hypoglycemic medication used to treat diabetes) injections for seven days during the assessment period. Further review of Section N. revealed at question N0415 High Risk Drug Classes, that they were not coded as having received a hypoglycemic medication. During an interview with the NHA and DON on March 6, 2024, at 11:50 AM, the aforementioned coding concern was shared for follow-up. Email communication received from NHA on March 7, 2024, at 11:47 AM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. During a follow-up interview with the NHA and the Assistant DON on March 7, 2024, at 12:05 PM, the NHA indicated that she would expect the MDS to be completed accurately. Review of Resident 49's clinical record on March 5, 2024, at 11:36 AM, revealed diagnoses that included type II diabetes and generalized anxiety disorder (excessive worry about everyday issues and situations). Review of Resident 49's physician orders revealed an order for Lantus Solostar (long-acting insulin) 100 units/milliliter, give eight units daily for type two diabetes with hyperglycemia (high blood sugar). Review of Resident 49's MDS section N0415 high-risk drug classes: use and indication, revealed the facility failed to indicate Resident 49's use of hypoglycemic (including insulin) medication for two MDS assessments: the comprehensive MDS dated [DATE], and quarterly MDS dated [DATE]. Review of Resident 49's medication administration record for September 2023, October 2023, December 2023, and January 2024, revealed Resident 49 received Lantus Solostar insulin during the seven day look back period for both the comprehensive MDS dated [DATE] and the quarterly MDS dated [DATE]. Email communication on March 6, 2024, at 1:09 PM, with the NHA, revealed that Resident 49's quarterly and comprehensive MDS assessments had been reviewed and modifications were made. Additional email communication on March 6, 2024, at 1:13 PM, with the NHA revealed it was the expectation of the facility for MDS assessments to be accurate. Review of Resident 56's clinical record on March 5, 2024, at 2:00 PM, revealed diagnoses that included obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract, causing urine to back up into the kidney) and bacteremia (bacteria in the bloodstream). Further review of Resident 56's clinical record revealed Resident 56 was hospitalized [DATE], until January 31, 2024, for bacteremia due to complicated urinary tract infection (UTI). Review of Resident 56's hospital discharge summary revealed urine culture results dated January 29, 2024, showing Resident 56's urine was positive for multidrug resistant Enterobacter cloacae complex (MDRO - a type of bacterium associated with healthcare-related infections). Review of Resident 56's physician progress notes revealed a history and physical dated February 1, 2024, that stated, in part, .sepsis with Enterobacter secondary to UTI . Review of Resident 56's quarterly Minimum Data Set, dated dated dated [DATE], sections I1700 Multi drug resistant organism and I1200 Septicemia, revealed the facility failed to indicate Resident 56's diagnoses of sepsis and MDRO. Email communication on March 7, 2024, at 10:31 AM, with Employee 2 (Registered Nurse Assessment Coordinator), revealed that Resident 56's quarterly MDS had been reviewed and modifications were made. Email communication on March 7, 2024, at 12:28 PM, with the NHA revealed it was the expectation of the facility for MDS assessments to be accurate. Review of Resident 76's clinical record revealed diagnoses that included CKD and diabetes mellitus type II. Review of Resident 76's Comprehensive MDS with the assessment reference date of December 18, 2023, revealed in Section N. Medications at question N0350 that they had received insulin injections for seven days during the assessment period. Review of Resident 76's physician orders failed to reveal any orders for insulin. During an interview with the NHA and DON on March 6, 2024, at 11:55 AM, the aforementioned coding concern was shared for follow-up. Email communication received from the NHA on March 6, 2024, at 4:04 PM, confirmed that the MDS was coded in error and that a modification to the assessment was completed. She also indicated that she would expect the MDS to be completed accurately. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 8, 19, and 56). Findings include: Review of facility policy, titled Care Planning, with a last review date of December 7, 2023, revealed, in part: Presbyterian Senior Living will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by our Mission Statement as well as State and Federal guidelines . 10. The care plan will be updated electronically as needed; and 11. The care plan will be reviewed and evaluated for intervention effectiveness no less than quarterly. Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 8's care plan revealed a care plan problem for a pressure ulcer related to a deep tissue injury to the left heel, dated February 5, 2024. Further review of Resident 8's clinical record revealed that their pressure ulcer was resolved on February 20, 2024. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 6, 2024, at 11:50 AM, the above care plan concern was shared for further follow-up. An email communication received from the NHA on March 6, 2024, at 2:01 PM, confirmed that the care plan should have been revised when the pressure ulcer resolved. Review of Resident 19's clinical record revealed diagnoses that included ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area) and the presence of an automatic (implantable) cardiac defibrillator (pacemaker). Review of Resident 19's physician orders revealed an order to completed a pacemaker device remote check, dated September 19, 2023. Review of Resident 19's care plan failed to reveal any documentation of the presence of the defibrillator/pacemaker, the intervention of testing, or any safety measures needed. During an interview with the NHA on March 7, 2024, at 9:30 AM, the above concern was shared for further follow-up. During a follow-up interview with the NHA and Employee 2 (Registered Nurse Assessment Coordinator [RNAC]) on March 7, 2024, at 12:04 PM, Employee 2 confirmed that the pacemaker was not care planned and the care plan had been revised. The NHA confirmed that she would expect care plans to be comprehensive. Review of Resident 56's clinical record on March 5, 2024, at 2:00 PM, revealed diagnoses that included obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract, causing urine to back up into the kidney) and bacteremia (bacteria in the bloodstream). Further review of Resident 56's clinical record revealed Resident 56 was hospitalized [DATE], until January 31, 2024, for bacteremia due to complicated urinary tract infection (UTI). Review of Resident 56's hospital discharge summary revealed urine culture results dated January 29, 2024, showing Resident 56's urine was positive for multidrug resistant Enterobacter cloacae complex (MDRO [multi-drug resistant organism] - a type of bacterium associated with healthcare-related infections). Review of Resident 56's comprehensive plan of care revealed the facility failed to update the comprehensive care plan to include the new identification and diagnosis of an MRDO in the urine. During a staff interview March 7, 2024, at 12:02 PM, with the NHA and Employee 2, Employee 2 revealed Resident 56's care plan had been reviewed and updated. Email communication March 7, 2024, at 12:28 PM, with the NHA revealed it is the facility's expectation that the care plan would have been updated timely. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 18 residents reviewed (Resident 19). Findings include: Review of facility policy, titled Wound Care, with a last approved date of December 12, 2023, revealed, in part: Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate. Review of Resident 19's clinical record revealed diagnoses that included diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high), ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Observation of Resident 19 on March 4, 2024, at 1:38 PM, revealed the presence of dressings to their bilateral (both) lower legs. Review of Resident 19's physician orders revealed the following orders: cleanse open areas to lower legs, cover with Xeroform (a non-adherent type dressing), ABD (absorbent type dressing), and kling (a gauze type wrap) then apply ACE wraps (elastic type wrap), change every three days and as needed for soiling/lifting, dated January 22, 2024; and an order to cleanse open areas to lower legs, cover with Xeroform, ABD, and kling then apply ACE wraps change every three days and as needed for soiling/lifting, dated November 29, 2023. Review of Resident 19's clinical record under section titled Skin Condition, revealed it did not include any identified areas to their legs. Review of Resident 19's clinical record nurses notes from November 29, 2023, through March 5, 2024, at approximately 9:30 AM, revealed that there were various notes indicating that their dressings were intact or changed, but the notes failed to include any description of Resident 19's actual skin appearance. Review of Resident 19's physician progress note dated February 8, 2024, revealed that it did not include any assessment or documentation of Resident 19's skin condition on their bilateral lower extremities. Review of Resident 19's care plan revealed a problem for a chronic skin condition of dry skin that flakes off and exposes wounds, dated February 19, 2024, with no identified goal, and one intervention to apply treatment to legs as ordered, dated February 19, 2024. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on March 6, 2024, at 11:55 AM, the aforementioned concerns were shared for further follow-up and additional information was requested. During an interview with the ADON on March 6, 2024, at 2:02 PM, she indicated that she does not follow Resident 19 on her weekly wound rounds. She said that the nurses assigned to Resident 19 complete the dressing changes. Again, the concern was shared that there was no documentation of an assessment or evaluation of the condition or appearance of Resident 19's legs to identify if or what was present on their legs. ADON then indicated that the physician would be in tomorrow and could take a look at them to see what they are. It was, again, shared that there was no documentation of any assessment of Resident 19's skin condition to their bilateral lower legs from November 2023, through present. Email communication received from NHA on March 6, 2024, at 4:01 PM, included a copy of a progress note dated March 6, 2024, that indicated it was a late entry from March 4, 2024. This progress note indicated that Resident 19's treatment was provided to their bilateral lower legs. In addition, the note indicated that Resident 19's bilateral lower legs remained reddened with multiple scattered open areas from the top of right foot to their mid lower right thigh, and left leg from mid shin to upper knee; both with scattered open areas draining small serosanguinous (thin, slightly yellow fluid with a pink tinge) drainage. During an interview with the NHA and ADON on March 7, 2024, at 12:08 PM, the ADON indicated that they do not do skin sheets for chronic skin conditions. The concern was shared that the March 6, 2024, nurse's note indicated multiple scattered open areas with no measurements. She indicated that Resident 19 has a chronic skin condition in which skin flakes off and creates open areas, some of which could be very small in nature. She confirmed that there was no documentation of the size of the identified multiple open areas, and that she would expect staff to document a full evaluation or an assessment of these areas in their notes with dressing changes so that the effectiveness of the treatments could be determined and appropriate follow-up completed. As of March 7, 2024, at 1:15 PM, the facility had provided no other additional information. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on staff interviews, facility policy review, and review of facility legionella guidelines, it was determined the facility failed to implement a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia)); and failed to maintain accurate infection control data. Findings include: A review of the facility policy, titled Anticipated Increase in Legionellosis Cases Due to Seasonality, dated June 12, 2023, failed to address any baseline or annual testing in the facility for water-borne contaminants, such as Legionella. A review of the facility policy, titled Surveillance for Health-Care Associated Infections (HAI), last reviewed February 22, 2024, stated, The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and Healthcare-Associated Infections, to permit interventions to try to slow or stop the transmission of such infections. A review of the facility guidelines (toolkit developed by CDC-Centers for Disease Control), titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, determined the need for a water management program based on risk analysis. The facility risks, based on analysis, included being a healthcare facility where residents stay overnight and have acute or chronic problems and weakened immune systems; Residents are primarily older than [AGE] years; and the building has multiple rooms (housing units) with a centralized hot water system. During an interview with the Nursing Home Administrator (NHA) on March 6, 2024, at 11:00 AM, the NHA was unable to show evidence of routine environmental sample results of Legionella testing. The NHA added that the facility was having difficulty finding a local service provider to perform Legionella testing. A review of the facility infection control (IC) monthly log (data that should minimally include a resident identifier, room location, confirmed type and area of infection, treatment), dated January 2024, revealed 26 residents were listed as suspected for an infection and 8 are listed as confirmed, but the IC logs were not updated for the 26 residents to show confirmation of an infection with microbiology (laboratory/x-ray reports that confirm infection, type of bacteria, and recommended antibiotic), or that the infection was ruled out. A look back at previous months of IC data revealed the same as above. Further review of the January 2024 infection control (IC) data log revealed Resident 56 was documented as being admitted [DATE]. Resident 56 was actually admitted [DATE]. Resident 56's infection was listed as suspected, but was actually confirmed with microbiology reports for both infections in the blood and urinary tract. The organism (type of bacteria or treatment) was never documented on the IC log. During an interview with the Infection Control Preventionist (ICP) on March 7, 2024, the ICP stated that the system marks all residents as suspected and only those residents who are reported to the state reporting system are marked as confirmed; therefore, the logs do not reveal all of the confirmed infections and accuracy for tracking infections. During an interview with the Nursing Home Administrator (NHA) on March 7, 2024, at approximately 11:30 AM, the NHA agreed that IC data should be accurate. 28 Pa. Code 201.18(b)(1)(3) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's physician's discharge summary included all required documentation for two of three residents reviewed for discharge (Residents 83 and 85). Findings include: Review of facility policy, titled Physician Services, with a last approved date of [DATE], revealed 13. The physician, CRNP [Certified Registered Nurse Practitioner], or PA [Physician Assistant] must complete a Discharge Summary that includes a recapitulation of the resident stay and pertinent instructions for continuity of care upon discharge. Review of Resident 83's clinical record on [DATE], at approximately 10:00 AM, revealed Resident 83 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and respiratory syncytial virus (RSV - virus that infects the respiratory system that causes mild cold-like symptoms that can be severe in elderly adults). Review of Resident 83's clinical record revealed that Resident 83's family elected hospice services after admission on [DATE]. Further review of the clinical record revealed that hospice services were started for Resident 83 on [DATE]. Review of Resident 83's clinical record revealed that between [DATE] and 8, 2023, Resident 83's health declined, and it was documented that Resident 83 exhibited less responsiveness, audible chest congestion, labored breathing, and loss of gag-reflex. Review of Resident 83's clinical record revealed that on [DATE], Resident 83 expired. Review of Resident 83's death certificate, signed and dated [DATE], revealed it documented Resident 83's immediate cause of death as acute cardiopulmonary collapse, with underlying causes of, pneumonia and rsv bronchitis. Review of Resident 83's physician discharge summary, signed [DATE], revealed it stated, Patient expired on [DATE] .dementia/[A]lzheimers. Review of available clinical documentation revealed Resident 83 had not previously been diagnosed with Alzheimer's dementia and did not expire as a result of Alzheimer's dementia. Further, the physician's discharge summary did not include a recapitulation of the Resident's stay that included course of illness and treatment, including the hospice admission, nor did it include accurate diagnosis information. As of [DATE], at 1:15 PM, the facility had no further information to provide. Review of Resident 85's clinical record revealed diagnoses that included Parkinson's disease (a long term degenerative disorder of the central nervous system that mainly affects the motor system), encephalopathy (broad term for any brain disease that alters brain function or structure), and muscle weakness. Review of Resident 85's clinical record revealed that they were transferred to the hospital on [DATE], that the Resident declined to hold their bed at the facility, and was, therefore, discharged . Review of Resident 85's physician discharge summary, signed [DATE], revealed it stated, Patient admitted to hospital, dropped behold. The only other information included on this discharge summary were the diagnoses of confusion and ambulatory dysfunction (difficulty walking). The discharge summary failed to include a recapitulation of the Resident's stay that included course of illness and treatment. During an interview with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing on [DATE], at 12:09 PM, the concern with the discharge summary was shared. The NHA indicated that she would review. Email communication received from the NHA [DATE], at 12:30 PM, indicated that she felt the summary was based on the physician's / nurse practitioner's assessment and that, although it was brief, it seemed to meet the regulation to her. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(xi) Medical records

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of six residents reviewed for unnecessary medications (Resident 61). Findings include: Review of facility policy, titled Management of Behavioral or Psychological Symptoms of Dementia-BPSD with or without Antipsychotic, with a last approved date of December 22, 2023, revealed the following, in part: The FDA [Food and Drug Administration] Black Box Warning Regarding Atypical & Conventional Antipsychotic in Dementia states, 'Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo; Residents/families/representatives should be involved in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings), the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives. The discussion should be documented in the resident's record; and D. Monitoring of behaviors/antipsychotic use through community At Risk committee at least annually with IDT to include pharmacist reviews of medication use. 1. Include gradual dose reduction attempts and results.' Review of facility policy, titled Medication Orders: IB3: Stop Orders, with a last review date of December 7, 2023, indicated, in part: A. The following medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. 7) PRN psychotropic medication orders - 14 days. Review of Resident 61's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning); anxiety (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities). Review of Resident 61's current physician orders on March 6, 2024, at approximately 10:15 AM, revealed an order for haloperidol (an antipsychotic medication), give 1 milligram as needed every 12 hours for behaviors, dated February 8, 2024, with no stop date indicated. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), on March 6, 2024, at 11:48 AM, the concern was shared that an antipsychotic medication was ordered PRN with no 14-day stop date implemented or documentation as to why the order was extended beyond 14 days. Additional information was requested. Email communication received from the DON on March 6, 2024, at 12:53 PM, indicated that Resident 61's routine Haldol was discontinued on February 8, 2024. The DON further indicated that Resident 61 had a history of significant behaviors, but that the facility staff and Resident 61's hospice provider felt that the routine dose could be discontinued and the PRN Haldol could be added in case it was needed to support hospice philosophy for end of life comfort. She further indicated that the PRN Haldol was used only once in February 2024 since the time the routine dose was discontinued. Review of Resident 61's February 2024 Medication Administration Record revealed that they received a PRN dose of the Haldol on February 27, 2024, at 8:42 PM; a total of 20 days after the order was originally written. Review of Resident 61's physician's progress note dated February 12, 2024, failed to include any documentation of Resident 61 being on Haldol or a rationale for continuing the PRN Haldol past the 14 day threshold. Email communication received from DON on March 6, 2024, at 1:19 PM, indicated that she would get the physician to put it in their progress note. Follow-up email communication sent to the DON on March 6, 2024, at 1:34 PM, reiterated the concern that this had not occurred at the time the medication was originally ordered, or at the 14-day point. Review of Resident 61's March 2024 Medication Administration Record on March 6, 2024, at 1:40 PM, revealed that they have not received any PRN doses of the Haldol thus far in March. Email communication was sent to the NHA on March 6, 2024, at 5:00 PM, requesting a copy of Resident 61's consent for the use of the antipsychotic medication (Haldol) or information to indicate that the resident's responsible party was educated on the risks versus benefits of the medication and their Abnormal Involuntary Movement Scale (a rating scale designed to measure involuntary movements known as tardive dyskinesia that can occur with the use of antipsychotic medications) screening results. During an interview with the NHA on March 7, 2023, at 9:19 AM, she indicated that they did not have any other documentation to provide. She said that there were no AIMS screenings completed and that there was no consent or documentation of risk versus benefit education with Resident 61's responsible party for the use of the Haldol at any point. She further indicated that they have processes in place for these to occur, but that they were missed for Resident 61, possibly because they were on hospice. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services for urinary catheters consistent with the resident's comprehensive plan of care for one of six residents reviewed for urinary catheters (Resident 63). Findings include: Review of Resident 63's clinical record on March 4, 2024, at approximately 1:00 PM, revealed diagnoses that included chronic kidney disease (CKD - decreased ability of the kidneys to filter toxin from the blood and produce urine) and osteomyelitis (infection of the bone) with sepsis (life threatening condition that results in dysfunction of the immune system entering the blood stream and causing inflammation in organs through out the body). Review of Resident 63's clinical record revealed Resident 63 utilized a urostomy (surgical opening to the bladder through the skin) with a catheter for urine elimination. Review of Resident 63's comprehensive plan of care revealed that Resident 63 had a care plan with the identified problem of, [Resident 63] has an ostomy to divert urine [related to] urostomy. Review of the goal of care plan revealed the goal was, [Resident 63] will have urinary diversion managed appropriately: drainage appropriate amount, type, color, odor, stoma correct size, pink free of breakdown and infection, surrounding skin free of breakdown, rash and infection. Review of the care plan interventions revealed one of the interventions for nursing staff were to, Check/record drainage (amount, type, color, odor). Observe for leakage. Review of Resident 63's clinical record revealed that staff were not recording the characteristics (amount, type, color, odor) of the urine drained from the urostomy bag. During a staff interview on March 7, 2024, at approximately 11:15 AM, Nursing Home Administrator confirmed that staff were not recording Resident urine characteristics and added that there was no physician order to do so. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident or resident's representative and the Office of the State Long-Term Care Ombudsman of resident transfers in writing and with the required transfer information for two of three residents reviewed for hospitalization s (Residents 29 and 81). Findings include: Review of Resident 29's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Parkinson's disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts). Further review of Resident 29's clinical record revealed she was transferred out to the hospital on January 23, 2023, to be evaluated for a fracture. Review of the monthly list for emergency transfers that was sent by the facility to the Office of the State Long-Term Care Ombudsman revealed that Resident 29 was not included in the list of transfers that occurred in January 2023. During an interview with the Nursing Home Administrator (NHA) on March 23, 2023, at 12:06 PM, she revealed that the Resident did not appear on the system generated list of resident transfers/hospitalization s, so she was missed when the ombudsman was notified of the transfers for January 2023. Review of Resident 81's clinical record revealed diagnoses that included stage 4 chronic kidney disease (gradual loss of kidney function) and anemia (condition that develops when the blood lacks enough healthy red blood cells). Further review revealed that Resident 81 was transferred to the hospital on February 17, 2023, and was subsequently admitted . An additional review of Resident 81's clinical record failed to reveal that written notification was provided to the Resident or his Representative regarding his transfer to the hospital, which included the following required contents: reason for transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. During an interview with the NHA on March 23, 2023, at 11:05 AM, she revealed that neither the Resident nor his Representative received a notice of transfer since the back of the notice that contained the transfer information was inadvertently not copied. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's status for two of 21 residents reviewed (Residents 64 and 69). Findings include: Review of Resident 64's clinical record revealed diagnoses that included fracture of thoracic vertebrae (middle part of the spine connecting the neck and back) and abnormality of gait and mobility. Review of Resident 64's current care plan revealed he was at risk for falls and lacked safety awareness. Further review revealed that he was to wear an Aspen collar (medical device worn around the neck that provides support as well as substantial motion restriction) at all times. This intervention was effective February 13, 2023. Observation of Resident 64 on March 20, 2023, at 10:44 AM, revealed him in his wheelchair in the hallway. He was not observed to be wearing a cervical collar. Review of nursing progress note dated December 21, 2022, revealed that Resident 64 was seen by neurosurgery who discontinued use of the Aspen cervical collar. During an interview with the Nursing Home Administrator (NHA) on March 23, 2023, at 12:10 PM, she confirmed that Resident 64's cervical collar was discontinued and that the care plan should have been updated when this occurred. Review of Resident 69's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and unspecified psychosis (abnormal condition of the mind that involves a loss of contact with reality). Review of Resident 69's current care plan on March 22, 2023, at 2:30 PM, revealed a care plan indicating that he desired to discharge to assisted living, with a noted discharge date of [DATE]. Review of clinical progress note dated January 10, 2023, revealed that a meeting was held that date with the interdisciplinary team and Resident's family member. Further review revealed that the Resident would be staying in long-term care. During an interview with the NHA on March 23, 2023, at approximately 12:00 PM, she revealed that she was unsure of why this information was appearing on the ongoing care plan since it was under the category of baseline plan of care. During an interview with the Registered Nurse Assessment Coordinator on March 23, 2023, at 12:31 PM, she revealed that baseline plan of care refers to a resident's discharge plan/status. She also confirmed that Resident 69 was not going to be able to return to assisted living, and that she had updated the care plan to reflect his current status. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 21 residents reviewed (Resident 285). Findings include: Review of facility policy, titled Specific Medication Administration Procedures under section titled Nebulizer with a review date of February 13, 2023, indicated the following: S. When treatment is complete, turn off nebulizer and disconnect the t-piece, mouthpiece, and medication cup. U. Rinse and disinfect the nebulizer equipment according to manufacturer recommendations or 1) Wash pieces (except tubing) with warm, soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel. W. When equipment is completely dry, store in a plastic bag with the Resident's name and date on it. Review of Resident 285's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 285's physician orders revealed an order for ipratropium-albuterol 0.5-3 (2.5) milligrams /(per) 3 milliliters (an inhaled respiratory medication/treatment administered via a small machine called a nebulizer) inhale one vial every six hours as needed for wheezing or shortness of breath. Observation of Resident 285 on March 21, 2023, at 11:40 AM, revealed their nebulizer treatment mask with medication chamber, still attached and not bagged, lying on nightstand on the Resident's left hand side of bed, beside a clear plastic bag that had no name or date noted. The nebulizer treatment tubing was dated March 19, 2023. Resident 285 was noted to be sitting a wheelchair on their right hand side of bed. Observation of Resident 285 on March 22, 2023, at 12:51 PM, revealed their nebulizer treatment mask with medication chamber, still attached and not bagged, lying on nightstand on the Resident's left hand side of bed, beside a clear plastic bag that had no name or date noted. The nebulizer treatment tubing was dated March 19, 2023. Resident 285 was noted to be sitting a wheelchair on their right hand side of bed. Employee 1 was shown the observation of nebulizer treatment mask on March 22, 2023, at 12:53 PM. Employee 1 indicated that the nebulizer treatment mask should be in the bag, lying next to the machine. She discarded the nebulizer treatment mask and medication chamber. Review of Resident 285's Medication Administration Record revealed that they had received an as needed medication nebulizer treatment on March 21, 2023, at 8:32 PM; and on March 22, 2023, at 6:02 AM. During an interview with Nursing Home Administrator (NHA) on March 23, 2023, at approximately 08:25 AM, the NHA was made aware of observations. The NHA indicated that she would have to review the policy in regards to it being bagged. Additionally, she wanted to look into it more because there are many variables and the Resident may have put it there. During a follow-up interview with NHA, Director of Nursing, and the Assistant Director of Nursing on March 23, 2023, at approximately 11:03 AM, the NHA indicated it was as observed and that she had no other information to provide. She further indicated that she would have expected the mask to have been bagged as per facility policy. 28 Pa code 211.12(d)(1)(2)-Nursing Services

Based on facility policy review, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure pharmaceutical services provide an accurate account for the disposition medication during the discharge process for one of three residents reviewed (Resident 82). Findings include: Review of facility policy, titled Disposal of Medications and Medication-Related Supplies with the last review date of February 13, 2023, revealed the following: D. The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the medication disposition form: 1) Date of destruction; 2) Resident's Name; 3) Name and strength of medication; and 4) Amount of medication destroyed; and E. The medication disposition form is kept on file in the facility according to policy, regulations, or applicable law. A review of the closed clinical record for Resident 82 on [DATE], revealed that Resident 82 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 82's clinical record revealed diagnoses that included hypertension (high blood pressure) and combined diastolic and systolic congestive heart failure (a condition in which the heart ventricles cannot produce enough pressure to push blood out of the heart and the ventricles also cannot relax, expand, or fill with enough blood). Further review of Resident 82's closed record revealed that there was no documentation of the disposition of their medications at the time of discharge. During an interview with the Nursing Home Administrator (NHA) on [DATE], at 10:46 AM, the NHA indicated that the nurses said that they were at the end of the medication cycle and there weren't that many medications left, so they just placed the meds in the drug buster (an eco-friendly drug disposal system in which the solution starts to dissolve medications on contact) and that the staff did not complete a medication disposition form. During a follow-up interview with the NHA, the Director of Nursing, and the Assistant Director of Nursing on [DATE], at approximately 11:05 AM, the NHA indicated that she would expect the Medication Disposition sheet to be completed at time of discharge. 28 Pa. Code 211.9(j)Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, as well as staff interview, it was determined that the facility failed to provide assistive feeding devices for one of 18 residents reviewed (Resident 29). Findings include: Review of Resident 29's clinical record revealed diagnoses that included Parkinson's disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 29's dietary orders revealed an order for food on a lipped plate and thin liquids in an adaptive cup with a lid and straw. This order was effective January 24, 2023. Observation on March 20, 2023, at 12:24 PM, revealed Resident 29 in bed, with her meal on her overbed table. Resident 29 was observed to be eating her meal with her hands. It was observed that her meal was served on a regular dinner plate, and her dessert was served on a smaller regular plate. Also present on her tray was a small plastic cup of water with a straw. During an immediate interview with Employee 6 (Nurse Aide), she confirmed that Resident 29 should have had lipped plates for her food. During an interview with the Nursing Home Administrator on March 23, 2023, at 11:15 AM, she revealed the expectation that Resident 29 should have been provided the appropriate adaptive eating equipment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that a resident's request to be resuscitated was carried out in accordance with the resident's advanced directive for one of 12 residents reviewed (Resident CR7), resulting in the resident's death due to a failure to perform cardiopulmonary resuscitation. Findings include: The facility's policy regarding cardiopulmonary resuscitation (CPR - an emergency procedure performed when someone's breathing or heartbeat stops), dated [DATE], revealed that all residents without observable signs of life would be resuscitated unless they had a do not resuscitate (DNR) order. A physician's orders [REDACTED]. physician's orders [REDACTED]. A nursing note, dated [DATE], revealed that Licensed Practical Nurse 7 entered Resident CR7's room at 11:35 a.m. and the resident's skin was cool to touch, his color was pale, and his nail beds, lips, and hands were cyanotic (bluish or purplish discoloration of the skin due to a lack of oxygen). A nursing note for Resident CR7, dated [DATE], revealed that Registered Nurse Manager 6 was called to the resident's room at 11:35 a.m. and entered the room at approximately 11:40 a.m. The resident's color was translucent white, his nail beds and lips were pale, he was found with no breath sounds, and no pulse. The resident had no response to physical sternal stimulation (technique used to assess the level of consciousness in a person who is not responding normally), his body was cool to touch, and there were no viable signs of life at 11:40 a.m. A witness statement from Occupational Therapist 5, dated [DATE], revealed that she, Physical Therapy Assistant 8, and the Resident CR7's spouse were in the resident's room when the resident became unresponsive. She was unable to get a reading of the resident's oxygen saturation (percentage of oxygen in the blood), and the resident's wife requested that Physical Therapy Assistant 8 go get the Registered Nurse Manager. Approximately one minute after Physical Therapy Assistant 8 left the room, Resident CR7 went into another episode of unresponsiveness and was gasping for breath. The resident was unresponsive for approximately two minutes when Occupational Therapist 5 ran out of the room to get assistance from nursing staff. Occupational Therapist 5 found Licensed Practical Nurse 7 and returned to the resident's room where Licensed Practical Nurse 7 attempted to arouse the resident and obtain a blood pressure, while Occupational Therapist 5 tried to arouse the resident and obtain an oxygen saturation reading. During this time, Registered Nurse Manager 6 and Physical Therapy Assistant 8 returned with an oxygen concentrator. Registered Nurse Manager 6 was on one side trying to find a heart beat or breath sounds while Licensed Practical Nurse 7 was on the other side trying to obtain a blood pressure reading. The nursing staff reported that they could not hear a heart beat. Registered Nurse Manager 6 stated to Licensed Practical Nurse 7 to call the physician. A witness statement from Physical Therapy Assistant 8, dated [DATE], revealed that when she returned to the resident's room and the resident was in another unresponsive episode, she ran out of the room to get an oxygen concentrator, but Licensed Practical Nurse 7 was coming down the hall with a concentrator. Licensed Practical Nurse 7 was checking the resident's blood pressure and could not find one. Registered Nurse Manager 6 was checking the resident's pulse and breathing, and one nurse asked the other nurse if the resident was a code and she did not hear an answer. There was no documented evidence that CPR was performed according to the resident's advanced directive. Resident CR7's death certificate, dated [DATE], revealed that the resident's immediate cause of death on [DATE], was sudden cardiac death. An interview with Licensed Practical Nurse 7 on [DATE], at 3:20 p.m. revealed that when she found Resident CR7 to have no pulse, respirations, or blood pressure, she did not think about going to check the resident's code status (full code or DNR). She denied hearing Registered Nurse Manager 6 tell her to go and check the resident's code status and confirmed that when she left the resident's room, she went to the nursing station and answered the phone because it was ringing like crazy. An interview with Registered Nurse Manager 6 on [DATE], at 3:25 p.m. revealed that when she noticed that Resident CR7 was not breathing, she asked Licensed Practical Nurse 7 to check the resident's chart to see what the resident's code status was, but Licensed Practical Nurse 7 never returned to let her know the resident's code status. She stated that she assumed that the resident was a no code (no CPR) because Licensed Practical Nurse 7 did not return to notify her of the resident's code status. She confirmed that she did not check the resident's code status, that CPR was not initiated, and that CPR should have been started on the resident. An interview with the Director of Nursing on [DATE], at 4:54 p.m. confirmed that the staff did not perform CPR as ordered for Resident CR7, and they should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE].

Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 12 residents reviewed (Resident CR7), resulting in the resident's death due to the failure to perform cardiopulmonary resuscitation as ordered by the physician and in accordance with the resident's advanced directive. Findings include: The facility's policy regarding abuse, dated [DATE], revealed that residents were to be protected from mistreatment, neglect, exploitation and misappropriation of property. The facility's policy regarding cardiopulmonary resuscitation (CPR - an emergency procedure performed when someone's breathing or heart beat stops), dated [DATE], revealed that all residents without observable signs of life would be resuscitated unless they had a do not resuscitate (DNR) order. A physician's orders [REDACTED]. physician's orders [REDACTED]. A nursing note for Resident CR7, dated [DATE], revealed that at 11:00 a.m. the resident was in the hallway in his wheelchair with fixed pupils and no verbal response for about 90 seconds. He was then alert and talking, denied chest or left arm pain, his color was slightly pale, and his breathing was slightly labored. The resident indicated that he was tired, did not want to go back to therapy, and was transferred into bed. There was no documented evidence that the physician was notified about the resident's episode. A nursing note, dated [DATE], revealed that Licensed Practical Nurse 7 entered Resident CR7's room at 11:35 a.m. and the resident's skin was cool to touch, his color was pale, and his nail beds, lips, and hands were cyanotic (bluish or purplish discoloration of the skin due to a lack of oxygen). A nursing note for Resident CR7, dated [DATE], revealed that Registered Nurse Manager 6 was called to the resident's room at 11:35 a.m. and entered the room at approximately 11:40 a.m. The resident's color was translucent white, his nail beds and lips were pale, he was found with no breath sounds, and no pulse. The resident had no response to physical sternal stimulation (technique used to assess the level of consciousness in a person who is not responding normally), his body was cool to touch, and there were no viable signs of life at 11:40 a.m. A witness statement from Occupational Therapist 5, dated [DATE], revealed that she, Physical Therapy Assistant 8, and the Resident CR7's spouse were in the resident's room when he became unresponsive. She was unable to get a reading of the resident's oxygen saturation (percentage of oxygen in the blood), and the resident's wife requested that Physical Therapy Assistant 8 go get the registered nurse manager. Approximately one minute after Physical Therapy Assistant 8 left the room, Resident CR7 went into another episode of unresponsiveness and was gasping for breath. The resident was unresponsive for approximately two minutes when Occupational Therapist 5 ran out of the room to get assistance from nursing staff. Occupational Therapist 5 found Licensed Practical Nurse 7 and returned to the resident's room where Licensed Practical Nurse 7 attempted to arouse the resident and obtain a blood pressure, while Occupational Therapist 5 tried to arouse the resident and obtain an oxygen saturation reading. During this time, Registered Nurse Manager 6 and Physical Therapy Assistant 8 returned with an oxygen concentrator. Registered Nurse Manager 6 was on one side trying to find a heart beat or breath sounds while Licensed Practical Nurse 7 was on the other side trying to obtain a blood pressure reading. The nursing staff reported that they could not hear a heart beat. Registered Nurse Manager 6 stated to Licensed Practical Nurse 7 to call the physician. A witness statement from Physical Therapy Assistant 8, dated [DATE], revealed that when she returned to the resident's room and the resident was in another unresponsive episode, she ran out of the room to get an oxygen concentrator, but Licensed Practical Nurse 7 was coming down the hall with a concentrator. Licensed Practical Nurse 7 was checking the resident's blood pressure and could not find one. Registered Nurse Manager 6 was checking the resident's pulse and breathing, and one nurse asked the other nurse if the resident was a code and she did not hear an answer. There was no documented evidence that CPR was performed according to the resident's advanced directives and physician's orders [REDACTED]. Resident CR7's death certificate, dated [DATE], revealed that the resident's immediate cause of death on [DATE], was sudden cardiac death. Interview with Licensed Practical Nurse 7 on [DATE], at 3:20 p.m. revealed that when she found Resident CR7 to have no pulse, respirations, or blood pressure, she did not think about going to check the resident's code status (full code or DNR). She denied hearing Registered Nurse Manager 6 tell her to go and check the resident's code status and confirmed that when she left the resident's room, she went to the nursing station and answered the phone because it was ringing like crazy. Interview with Registered Nurse Manager 6 on [DATE], at 3:25 p.m. revealed that when she noticed that Resident CR7 was not breathing, she asked Licensed Practical Nurse 7 to check the resident's chart to see what the resident's code status was, but Licensed Practical Nurse 7 never returned to let her know the resident's code status. She stated that she assumed that the resident was a no code (no CPR) because Licensed Practical Nurse 7 did not return to notify her of the resident's code status. She confirmed that she did not check the resident's code status, that CPR was not initiated, and that CPR should have been started on the resident. Interview with the Director of Nursing on [DATE], at 4:54 p.m. confirmed that the staff did not perform CPR as ordered for Resident CR7, and they should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE].