Every finding on record at Riverside Health & Rehab Center

Based on a review of facility documents and resident and staff interviews it was determined the facility failed to meet the dietary needs for one of 17 residents (Resident R2).Findings include: Review of Resident R2's record indicated the resident was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/30/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), malnutrition (lack of sufficient nutrients in the body), and a history of cancer. Review of a grievance submitted by Resident R2 on 7/27/26, indicated, [Resident R2] stated that she did not get a dinner tray on 7/26/26. [Resident R1] stated other resident did not get a dinner tray as well She was told there were dietary issues. During an interview on 8/20/26, at approximately 12:30 p.m. Resident R2 confirmed that she did not receive a dinner tray on 7/26/26, and stated she was told by staff that a total of four residents did not get their trays. When asked if she was provided a meal later in the evening, Resident R2 stated, I called Luciano's and ordered a pizza. Resident R2 stated that staff apologized, but still didn't bring any food up. Resident R2 stated that she had been informed that staff in the kitchen were arguing that day. During an interview on 8/20/26, at approximately 1:00 p.m. Dietary Manager Employee E5 was able to recall the incident, and confirmed that it occurred on a Sunday after he had left the building. Dietary Manager Employee E5 stated that there had been issues with the PM cook. Dietary Manager Employee E5 stated that he returned to the facility after being informed, arriving at approximately 9:00 p.m. and met with the resident and apologized. Dietary Manager Employee E5 confirmed that Resident R2 had ordered a pizza for her evening meal. During an interview on 8/20/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to meet the dietary needs for one of 17 residents. 28 Pa. Code: 201.18(b)(1) Management28 Pa. Code: 211.12(d)(3) Nursing services28 Pa Code: 211.6(a) Dietary Services

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the facility policy Elopement/Unauthorized Absence Policy dated 8/12/26, previously reviewed 7/2/25, indicated the facility will identify residents with potentiation and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/11/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of an Elopement Observation assessment completed on 6/15/26, indicated Resident R1 was at potential risk for elopement, and a Wanderguard (electronic monitoring bracelet) was placed. Review of Resident R1's plan of care initiated 6/15/26, indicated that Resident R1 is an elopement risk. Review of a progress note written by Registered Nurse (RN) Employee E1 dated 8/11/26, at 12:45 a.m. indicated, At approximately 12am staff notified this writer that resident was not in bed or his usuals locations. This nurse immediately initiated a sweep of the building. Notified DON (Director of Nursing) on duty that resident's location was unknown and a sweep was in progress. After completing a search of the building and the grounds outside upon entering the building resident was observed sitting outside of the administrative offices in the hallway inside the building. Resident stated he was looking for the people under his bed. Resident assessed for injuries. No injuries found. Resident assisted back to his room where a more thorough assessment was completed. Wanderguard on L (left) ankle functioning. Elopement system tested and functioning. DON notified that resident was observed sitting in the hallway inside the building. Review of a witness statement written by Registered Nurse (RN) Employee E2 stated, During my initial rounds at approximately 2350 (11:50 p.m.), this nurse entered the resident room and observed that the resident was not in his bed. I did not see or have direct contact with this resident prior to discovering that he was not in his room. This nurse, with other staff members, began searching for the resident. This nurse searched the facility, drove around the facility and [adjacent facility]. Review of a witness statement written by Licensed Practical Nurse Employee E3 stated, Supervisor made staff aware a resident was missing. Directed all staff to search all areas, all rooms, all bathrooms. Some were searching outside. The MIU (memory impaired unit) and 800-Hall searched and resident not there. Review of a witness statement written by Nurse Aide Employee E4 stated, As I was walking down the 200-Hall I heard and seen the 'missing resident' come out the back where admin (administration) offices are located. Resident was not in his wheelchair but an office chair. Other than that he seemed okay. On 8/12/26, the facility initiated a plan of correction that included:-A full nursing assessment was completed on Resident R1 to ensure no injury occurred.-The DON (Director of Nursing)/Designee updated elopement assessments on all residents.-A resident headcount was conducted, and all residents were accounted for.-Resident plans of care were updated as appropriate.-Elopement drills completed on all three shifts on 8/11/26, and 8/12/26.-The DON/Designee educated all staff on the elopement policy and actions to take if an elopement occurs.-Locking mechanism on administration door adjusted and repaired to latch without the need to manually pull the door closed.-Signage placed on the locking door to the administration area reminding staff to ensure the door lock engages.-All facility doors were audited to ensure they were secure. The facility demonstrated compliance on 8/12/26. Review of Resident R1's clinical record on 8/20/26, revealed the elopement assessment and care plan were updated to include information on his elopement, risk for further elopement, and interventions. During five interviews on 8/20/26, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 8/20/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision to prevent elopement for one of four residents. This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen.Findings include:Review of the Dietary Services policy, Sanitation dated 9/12/25, indicated food and nutrition services staff will maintain a clean and sanitary environment in food services areas through compliance with a written, comprehensive cleaning schedule. During an observation of the Main Kitchen on 1/6/26, at 9:05 a.m. revealed the following:-Dishwasher was not reaching temperature to effectively sanitize.-Plate warmer was not operational.-Hole in the ceiling related to a pipe burst. Hole was covered with plastic and pipe was fixed.-Styrofoam was being used to serve the residents. During an interview at this time, Dietary Manager Employee E40 confirmed that they were using Styrofoam to serve the residents due to the dishwasher and plate warmer not being in working order.During a second observation of the Main Kitchen on 1/7/26, at 1:48 p.m. the following was observed:-Hole in the ceiling now had two fans placed in the ceiling with extension cords hanging down from the hole.-Dehumidifier was placed in the kitchen to remove excess moisture. -Three-compartment sink in the food preparation area was noted to have drainage hose from the dehumidifier wrapped around the facet. The drainage hose was attached to the dehumidifier on the floor, along to the three-compartment sink, and then down to the drain.During an interview at this time, Dietary Manager Employee E40 confirmed that dehumidifier and fans were placed by the restoration company due to the discovery of free-standing water behind the wall. During an interview on 1/15/26, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen and one of two nursing unit nutrition rooms.28 Pa. Code: 211.6(c) Dietary services.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on infection control for two of ten staff members Nurse Aide Employee E9 and Dietary Aide Employee E10). Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on infection control. Nurse Aide (NA) Employee E9 had a hire date of 7/1/23, failed to have infection control in-service education between 7/1/24, and 7/1/25. Dietary Employee E10 had a hire date of 7/1/23, failed to have infection control in-service education between 7/1/24, and 7/1/25. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on infection control for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on facility policy, observations, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during medication administration for two of four Licensed Practical Nurses (LPN) (Employees E5 and E11).Review of facility General Dose Preparation and Medication Administration dated 9/12/25, indicated, Medications should not come in contact with any surface except for the medication cup and, Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package. During an observation on 1/6/26, at approximately 8:30 a.m. LPN Employee E5 was observed opening bottles of over the counter medications, pouring the tablets into the palm of her hand, then placing the tablets in the medication cup. During an observation on 1/8/26, at approximately 9:00 a.m. LPN Employee E1 was observed popping the tablets/capsules from the medication blister packs into the palm of her hand, then placing the tablets in the medication cup. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to prevent the potential for cross-contamination during medication administration for two of four Licensed Practical Nurses.

Based on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meetings (second and third quarters).Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 2025, failed to reveal a quarterly meeting with at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.During an interview on 1/8/26, at 12:20 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meeting (second and third quarters), as required.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of in two of three medication rooms (700-Hall medication room and [DATE]-Hall medication room).Findings include:Review of the facility policy Storage and Expiration Dating of Medications and Biologicals dated [DATE], indicated, Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.During an observation on [DATE], at 2:18 p.m. of the 700-Hall medication room, the following was noted:(5) Packages of Xeroform with an expiration date of [DATE].(8) Packages of oil emulsion dressings with an expiration date of 05/2023(2) Central Line Dressing Trays with an expiration date of [DATE](2) Luer Lock Y-Sites with an expiration date of [DATE].(1) Administration Sets with an expiration date of [DATE].(4) IV Start Kits with an expiration date of [DATE].(10) Injection Site Ultrasite with an expiration date of [DATE].(8) IV Catheters with an expiration date of [DATE].(4) IV Catheters with an expiration date of [DATE].(2) IV Extension Sets with an expiration date of [DATE].Open and partially used vial of Tubersol, without an open date.During an observation on [DATE], at 2:30 p.m. of the Emergency Cart located in the 700-Hall medication room, the following was noted:(3) Yankauer with an expiration date of [DATE].(1) Dressing Change Kits with an expiration date of [DATE].(1) Central Line Dressing Change Kit with an expiration date of [DATE].(1) IV Start Kit with an expiration date of [DATE].(1) Luer Lock Y-Sites with an expiration date of [DATE].(1) Bottles of sterile normal saline with an expiration date of [DATE].(2) Bottles of sterile normal saline with an expiration date of [DATE].(1) Bottles of sterile water with an expiration date of [DATE].(4) IV Catheters with an expiration date of [DATE].(1) Injection Site Ultrasite with an expiration date of [DATE].(4) Heparin flushes an expiration date of [DATE].During an interview on [DATE], at approximately 2:45 p.m. the Registered Nurse Employee E6 confirmed the expired items in the 700-Hall medication room.During an observation on [DATE], at 11:00 a.m. of the [DATE]-Hall medication room, the following was noted:(73) 3ml syringes with an expiration date of 01/2022.(4) vials of lidocaine 1% with an expiration date of 08/2025.(5) culture swabsticks with an expiration date of [DATE].(7) IV Catheters with an expiration date of [DATE].(2) IV Catheters with an expiration date of [DATE].(1) Vacutainer with an expiration date of [DATE].(9) pH test kits with an expiration date of [DATE].(2) pH test kits with an expiration date of [DATE].(2) Containers for coagulation test kits with an expiration date of [DATE].During an interview on [DATE], at 11:06 a.m. the Assistant Director of Nursing confirmed the expired items in the [DATE] medication room.During an interview on [DATE], at approximately 11:20 a.m the Director of Nursing and the Nursing Home Administrator confirmed the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of in two of three medication rooms.28 Pa. Code: 201.14 (a) Responsibility of Licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.19 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain controlled substances were accounted for accurately for seven of thirteen residents (Resident R1, R5, R32, R53, R60, R113, R115).Findings include: Review of the facility policy General Dose Preparation and Medication Administration dated 9/12/25, indicated for staff to Document the administration of controlled substances in accordance with applicable law. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record revealed that Resident R53 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/23/25, included diagnoses of coronary artery disease (CAD, damage or disease in the heart's major blood vessels) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time. Review of Section C revealed Resident R1's BIMS score to be 15. Review of a physician's order dated 1/1/26, indicated Resident R53 received hydromorphone (narcotic pain medication) 4 mg three every four hours as needed for pain. During an interview and observation on 1/6/26, at approximately 8:30 a.m. Licensed Practical Nurse (LPN) Employee E5 reviewed the electronic medication administration record (MAR) and noted that Resident R53 was not documented as having received hydromorphone since 1/5/26, at 3:59 p.m. LPN Employee E5 stated she was told in report that Resident R53 had been given hydromorphone just prior to shift change (7:00 a.m.). Review of Resident R53's MAR revealed that hydromorphone 4 mg was signed out on the paper controlled medication utilization record (sign-out sheet) on 1/6/26, at 2:50 a.m. and 6:55 a.m. During an interview on 1/6/26, at approximately 8:35 a.m. when asked if he received pain medication throughout the night, Resident R53 stated he probably slept the middle of the night dose, and he might have gotten the dose before shift change. Further review of Resident R53's sign-out sheet, from 1/2/26, through 1/6/26, revealed additional doses of hydromorphone signed out on paper and not documented in the electronic medical record:01/02/26: 4 mg at 4:10 a.m.01/02/26: 4 mg at 1:45 p.m.01/03/26: 4 mg at 9:06 p.m.01/05/26: 4 mg at 10:35 a.m.01/05/26: 4 mg at 6:30 p.m.01/05/26: 4 mg at 10:45 p.m. Review of Resident R1's sign-out sheet, from 11/27/25, through 1/5/26, revealed additional doses of oxycodone (narcotic pain medication) signed out on paper and not documented in the electronic medical record:11/29/25: 5 mg at 9:30 a.m.12/04/25: 5 mg at 10:17 p.m.12/05/25: 5 mg at 12:00 p.m.12/18/25: 5 mg at 9:18 a.m.12/20/25: 5 mg at 12:27 p.m.01/05/26: 5 mg at 9:00 p.m. Review of Resident R5's sign-out sheet, from 12/19/25, through 1/5/26, revealed additional doses of oxycodone signed out on paper and not documented in the electronic medical record:12/20/25: 5 mg at 6:00 a.m. Review of Resident R32's sign-out sheet, from 1/3/26, through 1/6/26, revealed additional doses of oxycodone signed out on paper and not documented in the electronic medical record:01/04/26: 2.5 mg at 11:00 a.m.01/05/26: 2.5 mg at 2:40 p.m. Review of Resident R60's sign-out sheet, from 12/12/25, through 1/5/26, revealed additional doses of tramadol (narcotic pain medication) signed out on paper and not documented in the electronic medical record:12/12/25: 50 mg at 7:00 a.m.12/12/25: 50 mg at 1:00 p.m.12/17/25: 50 mg at 9:00 a.m.12/17/25: 50 mg at 9:00 p.m.12/18/25: 50 mg at 6:30 p.m.12/20/25: 50 mg at 9:00 a.m.12/22/25: 50 mg at 9:30 a.m.12/24/25: 50 mg at 9:00 a.m.12/29/25: 50 mg at 9:00 a.m.01/01/26: 50 mg at 3:00 p.m.01/02/26: 50 mg at 10:30 a.m.01/03/26: 50 mg at 10:00 a.m.01/05/26: 50 mg at 9:00 a.m. Review of Resident R113's sign-out sheet, from 12/12/25, through 1/5/26, revealed additional doses of tramadol signed out on paper and not documented in the electronic medical record:12/15/25: 50 mg at 9:00 a.m.12/17/25: 50 mg at 9:00 a.m.12/29/25: 50 mg (no time documented).01/02/26: 50 mg at 8:30 p.m.01/05/26: 50 mg at 9:00 a.m. Review of Resident R115's sign-out sheet, from 12/11/25, through 1/5/26, revealed additional doses of oxycodone signed out on paper and not documented in the electronic medical record:12/15/25: 5 mg at 9:30 a.m.12/16/25: 5 mg at 8:00 p.m.12/17/25: 5 mg at 10:00 p.m.12/22/25: 5 mg at 9:13 p.m.12/24/25: 5 mg at 8:15 p.m.12/28/25: 5 mg at 9:00 p.m.12/31/25: 5 mg at 9:00 p.m.01/05/26: 5 mg at 10:30 p.m. During an interview on 1/8/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain controlled substances were accounted for accurately for seven of thirteen residents. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa. Code: 201.29(j) Resident rights.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms assessable to resident's and visitor's from a wheelchair on one of six nursing units (700 Hall Memory Unit), failed to have a grievance box and forms accessible for four of four grievance boxes (Front Hall, Activities Room, Nurses Station 1, and Nurses Station 2) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) for three of four grievance boxes (Nurses Station 1, Nurses Station 2, and 700 Hall Memory Unit).Findings include:A review of facility policy Resident Grievances and Concerns dated 9/12/25, indicated the facility recognizes that residents have the right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make available to all residents via a posting in a prominent location in the facility, information of the right to file grievances orally or in writing; the right to file grievances anonymously; contact information for the Grievance Official; a reasonable time frame for completing the review of the grievance; the right to obtain a written decision regarding the grievance; and contact information of independent entities with whom grievances may be filed (e.g., State agency, Quality Improvement Organization, State Long-Term Care Ombudsman Program or protection and advocacy system).During an observation on 1/6/26, at 12:40 p.m. revealed a grievance box in the front lobby blocked by two wheelchairs. During an interview on 1/6/26, at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E13 stated residents can get grievance forms from the nurses at the nurses' stations. She stated the residents must ask for the grievance forms from staff, because they are kept behind the desk at both nurse's stations.During an observation on 1/6/26, at 12:43 p.m. revealed a grievance box located in the Activity Room blocked by storage items (a folded table, boxed room divider, empty yellow PPE (personal protective equipment) cart, an over-the-bed table, and a laundry bin used for soiled bibs. The grievance official name and contact information was not posted.During an interview on 1/6/26, at 12:50 p.m. LPN Employee E11 stated a grievance box was in the front lobby, or she would ask the supervisor, and point the resident in the correct direction.During an observation on 1/6/26, at 2:00 p.m. the grievance box and forms located in the 700 Hall Memory Unit were over 51 inches from the floor, making them assessable from a wheelchair.During an interview on 1/6/26, at 2:00 p.m. Social Worker Employee E3 confirmed residents and visitors did not have access to file a grievance due to items blocking the boxes, forms not readily available, and a box not accessible from a wheelchair.28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of thirteen residents (Resident R1, R50, R89, R94, R95, R103, and R114).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood.Resident R1 had an MDS completed on 11/29/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R1 was understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R1 is rarely understood, and the BIMS assessment was not completed. Resident R50 had an MDS completed on 11/28/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R50 was usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R50 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R50 is rarely understood, and the Resident Mood Interview was not completed. Resident R89 had an MDS completed on 11/21/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R89 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R89 is rarely understood, and the BIMS assessment was not completed. Resident R94 had an MDS completed on 12/20/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R94 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R94 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R94 is rarely understood, and the Resident Mood Interview was not completed. Resident R95 had an MDS completed on 10/20/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R95 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R95 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R95 is rarely understood, and the Resident Mood Interview was not completed. Resident R103 had an MDS completed on 12/9/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R103 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R103 is rarely understood, and the BIMS assessment was not completed. Resident R114 had an MDS completed on 12/14/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R114 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R1114 is rarely understood, and the BIMS assessment was not completed.During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of thirteen residents 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide Employees E8 and E9).Findings include:Review of facility provided documents and training records revealed the following staff members did not have 12 hours of in-service education:NA Employee E8 had a hire date of 7/1/23, with 4.10 hours of in-service education between 7/1/24, and 7/1/25.NA Employee E9 had a hire date of 7/1/23, with 0.00 hours of in-service education between 7/1/24, and 7/1/25.During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure equipment was in safe operating condition for one of two crash carts (carts maintained with equipment used in emergencies) (700-Hall crash cart).Findings include: Review of the facility policy Emergency Equipment Check Policy dated 9/12/25, indicated, Emergency equipment/cart[s] will be checked daily and items which are outdated or opened will be replaced. During an observation on 1/6/26, at 2:30 p.m. of the Emergency Cart located in the 700-Hall medication room, the following was noted:(3) Yankauer with an expiration date of 2/28/24.(1) Dressing Change Kits with an expiration date of 3/20/25.(1) Central Line Dressing Change Kit with an expiration date of 1/31/24.(1) IV Start Kit with an expiration date of 6/30/25.(1) Luer Lock Y-Sites with an expiration date of 4/13/22.(1) Bottles of sterile normal saline with an expiration date of 9/1/25.(2) Bottles of sterile normal saline with an expiration date of 10/1/25.(1) Bottles of sterile water with an expiration date of 6/1/23.(4) IV Catheters with an expiration date of 7/31/23.(1) Injection Site Ultrasite with an expiration date of 10/31/23.(4) Heparin flushes an expiration date of 12/31/24. During an interview on 1/6/26, at approximately 2:45 p.m. the Registered Nurse Employee E6 confirmed the expired items in the 700-Hall crash cart. Review of the Crash Cart MIU (memory impaired unit, 700-Hall) [DATE] checklist indicated that the crash cart had been checked daily, and all items were marked as present. No documentation was noted to indicate expired medications or supplies. During an interview on 1/7/26, at approximately 11:20 a.m the Director of Nursing and the Nursing Home Administrator confirmed the facility failed to ensure equipment was in safe operating condition for one of two crash carts. 28 Pa. Code: 201.14 (a) Responsibility of Licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.19 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for one of three residents (Resident R600).Findings include: The form Notice Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 indicated a Medicare provider/plan must deliver a completed copy of the NOMNC to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to the last day or services if care is not being provided daily. Review of the clinical record revealed Resident R600 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness, and GERD (acid reflux). Resident R600 discharged home with home health services on 12/5/25.During an interview on 1/7/26, at 1:40 p.m. Field Medicaid Specialist Employee E12 was unable to provide a signed copy of the NOMNC for Resident R600. Field Medicaid Specialist Employee E12 confirmed the NOMNC should have been completed and available for review.28 Pa. Code: 201.29(e) Resident rights.

Based on clinical record review, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity during medication administration for each resident's quality of life for one of four residents observed (Resident R52).Findings:Review of facility policy General Dose Preparation and Medication Administration reviewed 9/12/25, indicated during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.6 - Observe each resident's privacy and rights in accordance with applicable law (e.g., knocking before entering the room, pulling privacy curtains, informing resident what is to occur before administration, blocking unnecessary access to the MAR [Medication Administration Record]).Review of facility policy Resident Rights and Facility Responsibilities Policy reviewed 9/12/25, indicated it is the facility's policy to comply with all Resident's Rights. Staff will receive education on Resident's Rights upon hire and annually thereafter. Review of the Resident's Rights required by Title XIX of the Social Security Act of 1965, indicated Privacy: You have the right to privacy with regards to accommodations, medical treatment, written and telephone communications, visits and meetings with family and other resident groups.Review of the clinical record indicated Resident R52 was admitted to the facility on [DATE], with diagnoses that included dementia (decline in memory, thinking, and social abilities, and daily functioning), depression, and diabetes.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/29/25, indicated the diagnoses remain current.During an observation on 1/7/25, at 10:31 a.m. Licensed Practical Nurse (LPN) Employee E1 was observed administering Resident R52's medications in the Activities Room, during an ongoing activity with other residents nearby in the same activity.During an interview on 1/7/25, at 10:33 a.m. Licensed Practical Nurse (LPN) Employee E1 stated she did not think Resident R52 had a physician order to dispense medication in a common room.Review of physician orders for Resident R52 failed to indicate medications are allowed to be administered in a common room. Review of the electronic Medication Administration Record (eMAR) on 1/7/26, indicated LPN Employee E1 administered the following medications to Resident R1:-Escitalopram 5 mg (milligram), one tablet by mouth (for depression)-Metformin 500 mg, one tablet by mouth (for diabetes)-Miralax 17 grams, one dose (for constipation)-Omeprazole 20 mg, one tablet by mouth (for acid reflux)-Senna 8.6 mg, two tablets by mouth (for constipation)-Multivitamin with Iron, one tablet by mouth (supplement)Review of the care plan failed to indicate Resident R52 gave consent to receive medications administered in common areas.During an interview on 1/7/26, at 2:00 p.m. the Director of Nursing confirmed the facility failed to provide an environment and care to promote privacy and dignity for Resident R52.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for three of ten staff members (Nurse Aide Employees E8 and E9 and Dietary Aide Employee E10).Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on behavioral health. Nurse Aide (NA) Employee E8 had a hire date of 7/1/23, failed to have behavioral health in-service education between 7/1/24, and 7/1/25. Nurse Aide (NA) Employee E9 had a hire date of 7/1/23, failed to have behavioral health in-service education between 7/1/24, and 7/1/25. Dietary Employee E10 had a hire date of 7/1/23, failed to have compliance and behavioral health education between 7/1/24, and 7/1/25. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on behavioral health for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for three of ten staff members (Employee E8, E9, and E10).Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on resident rights. Nurse Aide (NA) Employee E8 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/24, and 7/1/25. Nurse Aide (NA) Employee E9 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/24, and 7/1/25. Dietary Employee E10 had a hire date of 7/1/23, failed to have effective communication in-service education between 7/1/24, and 7/1/25. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of three residents reviewed for hospitalization. (Residents R1 and R102). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Review of facility Bed Hold Policy dated 9/12/25, indicated, It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. Review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE]. Review of Resident R1's minimum data set (MDS, periodic assessment of resident care needs) dated 11/29/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R1 had moderate cognitive impairment. Review of a progress note dated 9/26/25, at 9:59 a.m. indicated that Resident R1 was transported to the hospital for out-of-range laboratory blood work. Review of a progress note dated 10/20/25, at 10:36 a.m. indicated that Resident R1 was transported to the hospital for malodorous drainage into wound vac. Further review of Resident R1's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the resident or resident representative upon transfer on 9/26/25, and 10/20/25. Review of the clinical record indicated Resident R102 was admitted to the facility on [DATE]. Review of Resident R102's MDS dated [DATE], included diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty maintaining balance). Review of Section C: Cognitive Patterns indicated Resident R102 had moderate cognitive impairment. Review of a progress note dated 9/26/25, at 6:48 p.m. indicated CNA (nurse aide) went in resident room to check on resident, resident had removed clothes, binder was in place, resident had pulled out peg tube. RNS (registered nurse supervisor) notified. MD (doctor of medicine) notified and ordered for resident being sent out for peg tube replacement. Further review of Resident 44's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the resident or resident representative upon transfer. During an interview on 1/8/26, at approximately 12:20 p.m. the Nursing Home Administrator confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of three residents reviewed for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for three of ten staff members (Employee E8, E9, and E10).Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on QAPI. Nurse Aide (NA) Employee E8 had a hire date of 7/1/23, failed to have QAPI in-service education between 7/1/24, and 7/1/25. Nurse Aide (NA) Employee E9 had a hire date of 7/1/23, failed to have QAPI in-service education between 7/1/24, and 7/1/25. Dietary Employee E10 had a hire date of 7/1/23, failed to have QAPI in-service education between 7/1/24, and 7/1/25. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on compliance and ethics for three of ten staff members (Nurse Aide Employees E8 and E9, and Dietary Employee E10).Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on compliance and ethics. Nurse Aide (NA) Employee E8 had a hire date of 7/1/23, failed to have compliance and ethics in-service education between 7/1/24, and 7/1/25. Nurse Aide (NA) Employee E9 had a hire date of 7/1/23, failed to have compliance and ethics in-service education between 7/1/24, and 7/1/25. Dietary Employee E10 had a hire date of 7/1/23, failed to have compliance and ethics in-service education between 7/1/24, and 7/1/25. During an interview on 1/8/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on compliance and ethics for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).Findings include:Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included Clostridium difficile (C. diff - highly contagious bacterium that causes diarrhea and colitis), diabetes, and high blood pressure. Resident R1 was on respite (provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends) stay for seven days.Review of the clinical record indicated Resident R1 was seen by the wound doctor on 10/13/25, with the following orders:Wound #1 Left, Plantar Foot: Cleanse Wound. Cleanse with 0.125% Dakin's Solution - and pat dry. Pack undermining, areas and wound bed with kling, cutting only once and leaving tail end visible out of wound bed. Cover with ABD and wrap with kerlix, and secure with tape. Change daily and prn.Wound #2 Right Buttock gluteus maximus: Cleanse Wound. Cleanse with warm soap and water (gentle scrub) - and pat dry. Use house stock barrier cream. Perform every shift and prn.Review of the progress notes reveal the wound note was entered as a late entry on October 17, 2025, at 4:08 p.m.Review of the physician orders indicated wound care orders were entered on 10/17/25. Resident R1 discharged from the facility on 10/17/25.During an interview on 11/19/25, at 12:40 p.m. the Director of Nursing confirmed the facility failed to ensure that a physician timely wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).28 Pa. Code: 211.12(d)(5) Nursing services.28 Pa. Code: 211.2(a) Physician services.28 Pa. Code: 211.5(f) Clinical records.

Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 14 of 22 residents (R6, R8, R22, R32, R38, R39, R44, R56, R57, R59, R65, R79, R150, R195). Findings Include: Review of facility policy Diabetic Protocol dated 1/2/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The staff will identify and report complications such as hypoglycemia. Review of the facility Hypoglycemia Policy dated 1/2/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. When acute hypoglycemia is suspected, assess mental status (alert, drowsy, uncooperative, or unconscious) and use glucometer to determine the resident's blood sugar level. A blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment do the following: -If the resident is conscious and treatment is indicated, give 1 tube of dextrose gel (15 grams). -After 15 minutes, repeat blood sugar and if still under 70 mg/dL, repeat glucose gel. -After 15 minutes repeat blood sugar. If above 70 mg/dL, give a snack of protein and a carbohydrate (ex. 1/2 sandwich with bread and a protein or crackers and a protein.) Monitor until stable. -If the resident is drowsy or unconscious or is unable or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously. Monitor the resident for 15 minutes after treatment. -If, after 15 minutes, the resident is conscious and able to consume orally, give a snack of a protein and a carbohydrate (ex. 1/2 a sandwich with bread and a protein or crackers and a protein). Monitor until stable; -If, after 15 minutes the resident still cannot consume anything orally, repeat glucagon 1 mg subcutaneously and call 911. Further review of the policy failed to reveal procedures in the event of a resident experiencing hyperglycemia. Review of the Facility assessment dated [DATE], indicated the facility will provide care for residents diagnosed with diabetes. Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. Review of the clinical record indicated that Resident R150 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/4/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) with hyperglycemia and severe chronic kidney disease (gradual loss of kidney function). Review of physician orders dated 11/30/24, 12/5/24, and 1/6/25, indicated to check blood sugar before meals, and call MD (Doctor of Medicine) for BS (blood sugar) <70 and >340. Review of Resident R150's plan of care failed to reveal goals and interventions related to diabetes and blood sugar level maintenance. Review of Resident R150's blood sugar record indicated that on 1/8/24, at 12:25 p.m. Resident R150's blood sugar was 509, documented by Licensed Practical Nurse (LPN) Employee E1. During an interview on 1/8/25, at approximately 2:30 p.m. LPN Employee E1 stated she had advised the Registered Nurse Supervisor (RNS) Employee E2 but had not had a response from her or the provider, and that no additional interventions or blood sugar rechecks had been completed on Resident R150. LPN Employee E1 further confirmed that the facility process is to notify the RNS, who then notifies the provider. During an interview on 1/8/25, at approximately 2:40 p.m. RNS Employee E2 stated she was not informed until 1:21 p.m. but she had not notified the provider stating, It is on my list. RNS Employee E2 confirmed no additional interventions or blood sugar rechecks had been completed on Resident R150. During an interview on 1/8/25, at approximately 2:45 p.m. the Director of Nursing (DON) confirmed that out of range blood sugar levels need to be addressed at the time of occurrence, and that a delay of greater than two hours was not appropriate. Further review of Resident R150's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/6: Result high 12/4: 448 Review of the clinical record indicated that Resident R195 was admitted to the facility on [DATE] and then readmitted [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperosmolarity (life threatening metabolic complication with severe high blood sugar) and lung cancer. Review of physician orders dated 12/21/24, indicated to check blood sugar twice a day (before breakfast and dinner), and call MD for BS <60 and >350. Review of Resident R195's plan of care failed to reveal goals and interventions related to diabetes and blood sugar level maintenance. During an interview on 1/8/25, at approximately 2:48 p.m. the Director of Nursing (DON) confirmed that out of range blood sugar levels need to be addressed at the time of occurrence, and that a delay of greater than two hours was not appropriate or documenting 24-48 hours later is not acceptable. Further review of Resident R195's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/1: Went out to the hospital for change in condition and no BS done per protocol 11/9: Result 59-Note placed 48 hrs later 11/7: Result High-No note showing notification or follow-up 9/25: Result 473-No note documented until 24 hrs later Review of the clinical record indicated that Resident R32 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and end stage renal disease (ESRD - an inability of the kidneys to filter the blood). Review of a physician order dated 11/9/24, indicated for Resident 32 to receive Glipizide extended release (oral medication to treat diabetes) once daily. Review of physician's orders for November 2024, failed to reveal an order to check Resident R32's blood sugar level. Review of Resident R32's plan of care failed to reveal goals and interventions related to diabetes. Review of a progress note dated, at 11/17/24, at 9:00 a.m. indicated, Notified by RN assigned to resident that resident was observed on floor. Resident assessed no injuries at time of incident. Resident states he hit head neuro-checks initiated at time of incident and noted with some confusion but resident baseline. Resident able to state place and time and current needs at time of incident. Review of a progress note written by RNS Employee E8 dated 11/17/24, at 6:47 p.m. indicated, Notified by nurse assigned to resident that resident has become more confused throughout the day. Assessed resident and resident noted with increased confusion and speaking in incoherent sentences. Resident speech noted slurred, noted unable to hold self-up in wheelchair. Resident skin noted pale in color, pupils unequal but reactive to light. Resident able to state name but unable to state where he was. Obtained order from doctor and resident sent out to [hospital] via ambulance. Review of Resident R32's dietary intake indicated he did not eat breakfast or lunch, and there was no documentation of dinner. Review of Resident R32's blood sugar record failed to reveal that his blood glucose level was checked at the time of the fall as a possible reason for the fall, and failed to reveal that his blood sugar was checked at his change in mental status as a possible reason. Review of a progress note dated 11/18/24, at 3:02 a.m. indicated Resident R32 was admitted to the hospital with a diagnosis of hypoglycemia. Review of a hospital note dated 11/18/24, at 3:31 p.m. indicated, Blood glucose monitoring found severe hypoglycemia and further stated, EMS (emergency medical services) checked BG (blood glucose) at nursing home and was noted to be 27. During an interview on 1/11/25, at 3:21 p.m. RNS Employee E8 confirmed she wrote the above note about Resident R32's change in condition, and stated the LPN who was assigned to Resident R32 stated she had checked Resident R32's blood sugar. Review of the clinical record indicated that Resident R44 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia, right leg-below knee amputation, high blood pressure and heart failure (heart doesn ' t pump blood as well as it should). Review of a physician orders dated 8/3/24, and remained current, indicated to check blood sugar before meals and to call MD for BS <70 and >340. Review of Resident R44's plan of care for diabetes diagnosis; Interventions do not include instructions for staff on actions to take for hyper/hypoglycemia. Further review of Resident R44's blood sugar record failed to reveal documentation of notification or follow-up for the following: 9/2: Result High-No note showing notification, Result 4:46 p.m. 368-no documentation of notification. 9/1: Result 445-No note showing notification or follow-up. 8/31: Results 5:39 a.m.: 405, 11:23 a.m.: 415 (insulin given, recheck-470 with no further notes for further instruction), 4:29 p.m.: 404-No documentation of notification or follow-up. 8/29: Result 4:59 p.m.: 526, 6:00 p.m.:557-instructed to give insulin but no order to repeat or if more insulin should be given after repeated. Result 8:27 p.m.: 478-no documentation. Review of the clinical record indicated that Resident R65 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia and dementia (group of thinking and social symptoms that interferes with daily functioning). Review of a physician orders dated 11/9/23, and remained current, indicated to check blood sugar before meals and at bedtime, to call MD for BS >420. Review of Resident R65's plan of care included a diabetes diagnosis. No further documentation or interventions regarding this was noted. Further review of Resident R65's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/22: Result 487-Note documented 12/23 (the next day) 12/5: Result 422-Note documented 12/6 (the next day) 7/13: Result High-Note documented 7/15 (Notes from 7/13 discuss resident receiving long-acting insulin at 7:29 p.m. and then the nurse attempting to give 6 Units of coverage but resident was screaming and punching people, so insulin not administered). 7/7: Result High-Note documented 7/8 (the next day) During an interview on 1/11/25, at 3:02 p.m. LPN Employee E3 reviewed with the surveyor the blood sugar level of 487 for Resident R65 on 12/22/24. LPN Employee E3 stated she usually puts in a note and is unsure why she did not that day. Review of the clinical record indicated that Resident R22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and dementia. Review of a physician orders dated 5/29/24, and remained current, indicated to check blood sugar twice daily at breakfast and dinner and to call MD for BS <70 and >400. Review of Resident R22's plan of care failed to reveal goals and interventions related to diabetes. Review of Resident R22's blood sugar record failed to reveal documentation of notification or follow-up for the following: 1/3: 412 12/11: 478 12/5: 411 11/14: 443 11/08: 400 10/27: 439 During an interview on 1/11/25, at 3:32 p.m. RN Employee E7 reviewed with the surveyor the blood sugar level of 478 on 12/11/24. RN Employee E3 stated she would have informed the RNS but was not able to provide a reason why it was not documented. Review of the clinical record indicated that Resident R38 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia and chronic kidney disease. Review of a physician orders dated 11/9/23, and remained current, indicated to check blood twice a day and to call MD for BS <70 and >420. Resident R38 is care planned for diabetes diagnosis. Further review of Resident R38's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/31: Result 441-No note showing notification or follow-up. 12/29: Result 401-No note showing notification or follow-up. 12/28: Result 470-No note showing notification or follow-up. 12/25: Result 415-No note showing notification or follow-up. 12/21: Result 499-No note showing notification or follow-up. 12/20: Result 470-No note showing notification or follow-up. 12/19: Result 484-No note showing notification or follow-up. 12/17: Result 524-No note showing notification or follow- up Review of the clinical record indicated that Resident R39 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes with hyperglycemia. Review of a physician orders dated 8/14/24, and remained current, indicated to check blood sugar before meals and at bedtime and to call MD for BS <70 and >450. Resident R39 is care planned for diabetes diagnosis. Further review of Resident R39's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/14: Result 574-Note documented 11/15 (the next day). 10/2: Result HIGH-No note showing notification or follow-up. Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes. Review of a physician orders dated 12/28/23, and remained current, indicated to check blood sugar twice a day and to call MD for BS <60 and >500. Resident R8 is care planned for diabetes diagnosis. Further review of Resident R8's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/27: Result HIGH-No note showing notification or follow-up. 12/13: Result HIGH-No note showing notification or follow-up. 12/1: Result HIGH-No note showing notification or follow-up. 11/19: Result HIGH-Note documented 11/20 (the next day). During an interview on 1/11/25, at 3:11 p.m. LPN Employee E5 reviewed with the surveyor the blood sugar levels of HIGH on 12/13/24, and 12/27/24. LPN Employee E5 stated always does a recheck but is unsure why it is not showing up in the electronic charting system. Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes. Review of a physician orders dated 12/28/23, and remained current, indicated to check blood sugar before meals and bedtime and to call MD for BS <60 and >500. Resident R6 is care planned for diabetes diagnosis. Further review of Resident R6's blood sugar record failed to reveal documentation of notification or follow-up for the following: 12/13: Result HIGH-No note showing notification or follow-up. 8/14: Result HIGH-No note showing notification or follow-up. During an interview on 1/11/25, at 3:11 p.m. LPN Employee E5 reviewed with the surveyor the blood sugar levels of HIGH on 12/13/24. LPN Employee E5 stated always does a recheck but is unsure why it is not showing up in the electronic charting system. Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease. Review of a physician orders dated 6/12/24, and remained current, indicated to check blood sugar twice a day and to call MD for BS <70 and >340. Resident R57 is care planned for diabetes diagnosis. Further review of Resident R57's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/28: Result 390-No note showing notification or follow-up. 11/14: Result 407-Note documented 11/15 (the next day). 9/6: Result 529-No note showing notification or follow-up. Review of the clinical record indicated that Resident R56 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes. Review of a physician orders dated 10/24/24, and remained current, indicated to check blood sugar before meals and at bedtime and to call MD for BS <70 and >400. Resident R56 is care planned for diabetes diagnosis. Further review of Resident R56's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/8: Result HIGH-No note showing notification or follow-up. Review of the clinical record indicated that Resident R79 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and dementia. Review of a physician order dated 3/8/24,and remained current, indicated to check blood sugar twice a day on Sunday, Monday, Wednesday, and Friday before breakfast and before dinner, check blood sugar twice a day on Tuesday, Thursday and Saturday between 11:00 a.m. and 2:00 p.m., 8:00 p.m. and 11:00 p.m., all without a sliding scale. Resident R79 is care planned for diabetes diagnosis only related to skin integrity. No information provided on hyper/hypoglycemia. Further review of Resident R79's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/18: Result Low-No documentation of notification or follow-up. Review of the clinical record indicated that Resident R59 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes mellitus and ESRD. Review of Resident R59's plan of care on 1/8/24, revealed that the care plan for diabetes did not include instructions for staff on actions to take for hyper/hypoglycemia. Review of a physician order dated 7/25/24, and remained current, indicated to check blood sugar before meals and to call MD for BS <70 and >340. Review of Resident R59's blood sugar record failed to reveal documentation of notification or follow-up for the following: 11/5/24: 49 During an interview on 1/8/25, at approximately 2:50 p.m. LPN Employee E3 was able to describe where to find parameters for notification on physician's order. Stated that she would notify RNS if blood sugar was out of range and document a nursing note in the medical record. During an interview on 1/8/25, at approximately 2:55 p.m. LPN Employee E4 stated low is below 70, and the high can be dependent on parameters in the physician's orders. Stated that if blood sugar was out of range she would notify the RNS, and if no response from RNS, she would text the provider directly. During an interview on 1/8/25, at approximately 3:00 p.m. LPN Employee E5 stated parameters are on the MD order, and she stated she would call the MD if outside the parameters. After prompting from the surveyor, stated she would document symptoms and follow-up in the medical record. During an interview on 1/8/25, at approximately 3:00 p.m. RN Employee E6 stated the parameters for blood sugar are on the sliding scale order. Stated for out of range blood sugars, she would recheck the blood sugar. Stated for high, she would call the doctor, and for low she would initially provide a snack and recheck. Stated she is often RNS, and staff report high and low blood sugars to her, and she notifies the provider. The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 1/9/24, at 1:34 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 1/9/24, at 6:29 p.m. an acceptable Corrective Action Plan was received which included the following interventions: After record review, it was determined that [the facility] failed to notify the physician of blood sugars out of range timely for 14 residents and care plans were absent or did not include approaches for diabetic emergency management. Immediate Actions: -Resident R150 was assessed by the Assistant Director of Nursing on 1/8/25 at 3:30 p.m. Resident had no s/s (signs or symptoms) of hyperglycemia at that time. -RNS Employee E2 spoke with the physician at 3:46 p.m. and reported the blood sugar of 509. The physician did not give any further orders. -Education was initiated on 1/8/25, with facility RNs and LPNs on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range. -On 1/9/25, Residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59's blood sugars were reviewed from the past 24 hours to ensure none were out of range without physician notification. -On 1/9/25, an ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was held, and the medical director was made aware of the findings. -On 1/9/25, the RN assessment coordinator is reviewing the care plans for residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59 to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management. This will be completed by 1/9/25, at 10:00 p.m. Like Residents: -Current residents with diabetes have the potential to be affected. Current residents with diabetes were reviewed on 1/8/25 by the ADON (Assistant Director of Nursing) to determine if blood sugars were out of range and none were noted out of range. -Current residents with diabetes are being reviewed by the RN assessment coordinator on 1/9/25, to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management and will be completed by 1/9/25 at 10:00 p.m. Correction of System: -Root cause analysis completed by the center QAPI committee on 1/9/25, and determined failure to follow the Resident Change in Condition policy led to the allegation. -To prevent recurrence, the Director of Nursing initiated education with facility RNs and LPNs including agency staff on 1/8/25, on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RNs and LPNs that were not on duty received education via phone and will receive in person education on their next scheduled shift. -Newly hired RNs and LPNs will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee. Monitoring: -To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars daily x 2 weeks, 3x a week x 2 week and then weekly x 2 weeks to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified, and new orders implemented as needed. -To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management 5 x a week for 2 weeks, then weekly x 3 weeks. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. On 1/10/24, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 1/10/24, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 9:00 a.m. on 1/10/24, five LPNs and RNs were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. During interviews beginning at approximately 1:30 p.m. on 1/10/24, three additional LPNs and RNs were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. The Immediate Jeopardy was removed on 1/10/24, at 2:13 p.m. when the action plan implementation was verified. During an interview on 1/13/24, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 14 of 22 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.