Every finding on record at Rolling Fields, Inc

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to review and revise comprehensive care plans by their goal date to reflect the current necessary care and services for four of 14 residents reviewed (Residents R1, R2, R9, and R31).Findings include: Review of facility policy entitled Formation of Resident Care Plan dated 7/10/26, indicated Care plans must be reviewed and revised: Quarterly, after any significant change in condition. and Revisions must be documented in the EMR [electronic medical record] with: Updated goals/interventions. Review of Resident R1's clinical record revealed an admission date of 4/14/18, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), polyosteorthritis (a condition that affects multiple joints all at one time leading to pain, stiffness, and reduced mobility) and pain in left ankle and joints of left foot. Review of Resident R1's person centered care plans revealed a care plan for pain with a goal date (a date on which the care plan should have been revised) of 5/15/26. Review of Resident R2's clinical record revealed an admission date of 10/31/19, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), unsteadiness on feet (the ability to maintain balance while standing), and bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows). Review of Resident R2's person centered care plans revealed care plans for psychotropic drug use and falls both with goal dates of 6/3/26. Review of Resident R9's clinical record revealed an admission date of 9/22/22, with diagnoses that included neuromuscular dysfunction of bladder (urinary bladder problem due to disease or injury of the nervous system involved in the control of urine), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow). Review of Resident R9's person centered care plans revealed a care plan for urinary with a goal date of 6/30/26. Review of Resident R31's clinical record revealed an admission date of 6/26/20, with diagnoses that included Hyperlipidemia (high cholesterol), localized edema (swelling in one area of the body), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and nicotine dependence. Review of Resident R31's person centered care plans revealed a care plan for smoking/smoking cessation with a goal date of 3/5/26. During an interview on 9/3/26, at 12:53 p.m. the Director of Nursing confirmed that Residents R1, R2, R9 and R31's care plans were beyond their goal dates. He/she also confirmed that the care plans should have been updated by the goal dates. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R6). Findings include:Review of facility policy entitled, Documentation for PRN Medication Utilizing Non-Pharmacological Methods dated 7/10/26, revealed Purpose: This documentation outlines the process for administering PRN medications and emphasizes the use of at least two non-pharmacological methods to address the patient's condition prior to medication administration. The goal is to provide comprehensive care by minimizing the reliance on pharmacological interventions, ensuring patient safety, and promoting comfort.Review of Resident R6's clinical record revealed an admission date of 5/26/26, with diagnoses that included dementia (a progressive brain disorder that interferes with activities of daily living), heart failure, and unspecified mood disorder. The clinical record revealed that on 6/23/26, Resident R6's physician ordered Lorazepam (medication ordered to treat anxiety) 0.5 milligrams (mg) every four hours PRN for anxiety and restlessness.Review of the July 2026 and August 2026 medication administration record (MAR) for Resident R6 revealed that the PRN Lorazepam was used on 7/1/26, 7/30/26, 7/31/26, 8/4/26, 8/5/26, 8/6/26, 8/10/26, 8/11/26, 8/12/26, 8/13/26, 8/18/26, 8/19/26, 8/26/26, 8/27/26, 8/29/26, and 8/31/26. Review of clinical records and progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the administrations listed above. During an interview on 9/3/26, at 11:48 a.m. the Director of Nursing confirmed that Resident R6's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications for the administrations listed above.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of one medication rooms reviewed and one of one medication carts reviewed (Fig Street medication room and cart).Findings include: Review of facility policy entitled Multidose Medications dated [DATE], indicated Staff will follow the manufacturer's or pharmacy's expiration/beyond-use date. Medications that are expired. or improperly labeled will not be used. Review of manufacturer's guidelines revealed that an open vial of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. Observations of drug storage on [DATE], at 2:25 p.m. of the Fig Street medication room revealed an open vial of Tubersol solution with an open date of [DATE]. Further observations revealed in the Fig Street medication cart an open vial of Lantus insulin with two discard dates, one of [DATE], and another of [DATE]. During an interview at the time of observations Licensed Practical Nurse Employee E1 confirmed that the vial of Tubersol had an open date of [DATE], which was beyond its use by date and the vial of Lantus insulin had two discard dates. He/she also confirmed that the vials of Tubersol and lantus insulin should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of a facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in a resident pantry for two of two refrigerators reviewed (Fig and Elmwood).Findings include: Review of facility policy entitled Cleaning Pantry Refrigerator dated 9/17/25, indicated Check all items for expiration dates and discard any items that are out of date and ensure all items belonging to Elders are labeled with Elders name and date.Observations on 9/22/25, at 2:22 p.m. of a refrigerator in the Fig wing pantry used for residents revealed a grocery bag with a half-eaten sandwich, an apple, a cookie and a bag of chips with no name or date and five containers of yogurt with an expiration date of 7/17/25. Observations of the freezer revealed ice packs used on resident body parts sitting next to an open container of ice cream and lemon swabs used to moisten resident mouths. Interview at the time of observations Nursing Assistant Employee E1 confirmed that the grocery bag with a half-eaten sandwich, apple, cookie and chips lacked a name or date; that the five containers of yogurt were beyond their expiration date; and the ice packs in the freezer used on resident body parts were sitting next to open container of ice cream and lemon swabs. He/she also confirmed that food items in the resident refrigerator should have a resident name and open date and should be discarded before or by their use by date and that the ice packs used on resident body parts should not be stored along with food.Observations on 9/22/25, at 2:35 p.m. of a refrigerator in the Elmwood wing pantry used for residents revealed in the freezer a milkshake with no lid and no name or date; a bowl of sherbert with no lid and no name or date; a frozen meal with no name or date; a breakfast wrap with no name or date and a best buy date of 7/17/25; and ice packs used on residents body parts sitting next to the uncovered milkshake and sherbet. Further observations revealed an employee's lunch box sitting in the refrigerator next to resident food items.During an interview at the time of observations Nursing Assistant Employee E2 confirmed that the milkshake, sherbet, and frozen meal lacked a name and date; the breakfast wrap was beyond its expiration date; ice packs used on resident body parts was sitting next to an open uncovered milkshake and sherbert; and an employee's lunch box was in the resident's refrigerator. He/she also confirmed that food items in the resident refrigerator should have a resident name and open date and should be discarded before or by their use by date and employees should not store their lunch boxes in the resident refrigerator.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on review of hospice contract, clinical records, and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained in the clinical record for one of one residents reviewed for hospice services (Resident R1).Findings include: Review of a facility contract with a local hospice services agency dated 4/2/25, indicated that .Hospice plan of care (referred to as hospice plan), hospice shall furnish a copy of the hospice plan . at the time of the resident's admission into the hospice program.Review of Resident R1's clinical record revealed an admission date of 7/15/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), malignant neoplasm of unspecified part of right bronchus or lung (lung cancer), and hyperlipidemia (high cholesterol). Review of Resident R1's physician orders revealed an order for a local hospice agency services dated 7/15/25.Resident R1's clinical record lacked evidence that the hospice agency provided the facility with a current hospice plan of care.During an interview on 9/24/25, at 2:20 p.m. the Director of Nursing confirmed that Resident R1's clinical record lacked evidence of the hospice agency's plan of care and also confirmed that Resident R1's clinical record should have a plan of care from the hospice agency.28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to include required components of recapitulation of stay (summary of resident's stay and course of treatment in the facility) for one of four closed records reviewed (Resident R50).Findings include: Review of facility policy entitled Recapitulation of Resident Stay dated 9/17/25, indicated that all residents discharged . have a complete, accurate and timely recapitulation of stay . and The facility shall complete a recapitulation of stay for all residents upon discharge .Review of Resident R50's clinical record revealed an admission date of 8/14/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), osteomyelitis (a bone infection), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones)Review of clinical record revealed that Resident R50 was discharged on 8/29/25.Review of Resident R50's clinical record revealed an incomplete recapitulation of Resident R50's stay and lacked the required components.During an interview on 9/25/25, at 10:50 a.m. the Director of Nursing (DON) confirmed that Resident R50's closed record lacked the required components of the recapitulation of his/her stay. The DON also confirmed that a complete recapitulation of Resident R50's stay should have been completed.28 Pa. Code 211.5(f)(i)(iv)(xi) Medical records

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days for one of five residents reviewed (Resident R2).Findings include: Review of facility policy entitled PRN Psychotropic Medication Use dated 9/17/25, indicated All PRN psychotropic orders are limited to 14 days. If continuation is required: The prescriber must document clinical justification.Review of Resident R2's clinical record revealed an admission date of 8/22/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes (a health condition that is caused by the body's inability to produce enough insulin) and generalized anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone).Review of Resident R2's medication administration record revealed an order for Vistaril (mediction to treat anxiety) 25 milligrams (mg) four times a day as needed with a stop date of 9/5/25, and another order for Vistaril 25 mg four times a day as needed with a start date of 9/9/25. Resident R2's clinical record lacked evidence of a clinical rationale for continued use beyond 14 days.During an interview on 9/24/25, at 12:33 p.m. the Director of Nursing confirmed that Resident R2's Vistaril lacked a clinical rationale for continued use beyond 14 days and also confirmed that to continue Resident R2's Vistaril a clinical rationale was needed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide resident privacy on one of two medication carts (Dogwood Medication cart). Findings include: Review of facility policy entitled Resident Rights Privacy & Confidentiality dated 7/5/24, indicated The facility limits access to any medical records to staff and consultants who provide direct care to the resident. And All records - medical, personal, financial or social service - will be safe-guarded at all times to insure confidentiality. Observation on Dogwood Hall on 10/29/24, at 11:13 a.m. revealed a medication cart sitting in the hallway against the wall with an open computer on top of the medication cart and resident health information visibly facing into the hallway. Continued observations revealed several visitors, residents and staff who walked past the visible health record information until the nurse returned to the medication cart at 11:25 a.m. During an interview on 10/29/24, at 11:25 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover resident health information that was on the computer on top of the medication cart. LPN Employee E1 also confirmed that resident information is to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to notify the physician regarding refusal of medication for one of 18 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication Administration dated 7/5/24, indicated Notify provider of any medication refused three times so that a determination can be made as to how to proceed . Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included Diabetes (a health condition that caused by the body's inability to produce enough insulin), Hypertension (high blood pressure), and Hemiplegia (a condition where a person is paralyzed and unable to move one side of their body). Review of Resident R1's physician's orders revealed an order dated 4/9/24, for Insulin Lispro four times a day to treat diabetes. Review of Resident R1's September 2024, Medication Administration Record (MAR) revealed Resident R1 refused his/her Insulin Lispro 111 times, and review of Resident R1's October 2024, MAR revealed Resident R1 refused his/her Insulin Lispro 118 times. During an interview on 10/30/24, at 1:00 p.m. the Director of Nursing confirmed that Resident R1 had refused his/her Insulin Lispro and the clinical record lacked evidence that the physician was notified. He/she also confirmed that the physician should have been notified after the third refusal. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for two of 18 residents reviewed (Resident R29 and R16 ). Findings include: Review of Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included multiple sclerosis (a disease resulting in nerve damage that disrupts communication between the brain and the body), benign prostatic hyperplasia (type of prostate enlargement resulting in slow or backflow of urine), spastic hemiplegia(condition that causes tightness and involuntary contractions in the limbs and extremities on one side of the body) and weakness. Review of Resident R29's clinical record revealed a physician's order dated 7/12/24, for a Texas catheter (type of external condom catheter to collect urine) to be placed on at bedtime and remove in morning. Review of the MDS dated [DATE], Bowel and Bladder Section H0100 Appliances revealed to check all that apply. Documentation on the MDS for H0100 revealed Resident R29 was marked for having an external catheter and an indwelling catheter. During an interview on 10/30/24, at 1:15 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident did not have an indwelling catheter. The RNAC also confirmed that Section H0100 of the MDS dated [DATE], was incorrectly coded for Resident R29 regarding an indwelling catheter. Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included Type II diabetes (condition where the pancreas does not make enough insulin), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty communicating). Resident R16's physician's order summary revealed that an Ozempic injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) was ordered by the physician on 9/5/24. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R16 received insulin one time during the seven day look back period. During an interview on 10/30/24, at 12:13 p.m. the Corporate RNAC confirmed that Section N - Medications category N0350A Insulin of the Quarterly MDS dated [DATE] was incorrectly coded for Resident R16 and should have been zero days. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to update a care plan for one of 18 residents reviewed (Resident R29). Findings include: Review of a facility policy entitled Formation of the Resident Care Plan dated 7/5/24, indicated that, care plans are periodically reviewed and revised by a team of qualified persons after each assessment. Review of Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included multiple sclerosis (a disease resulting in nerve damage that disrupts communication between the brain and the body), benign prostatic hyperplasia (type of prostate enlargement resulting in slow or backflow of urine), spastic hemiplegia(condition that causes tightness and involuntary contractions in the limbs and extremities on one side of the body) and weakness. Review of Resident R29's clinical record revealed a physician's order dated 7/12/24, for a Texas catheter (type of external condom catheter to collect urine) to be placed on at bedtime and removed in morning. Review of clinical record documentation for Resident R29 revealed there was no evidence that the care plan was updated to reflect the Texas catheter. During an interview on 10/30/24, at 1:15 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R29's care plan was not updated to reflect the Texas catheter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility policies, facility documentation, and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for one of 18 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication Administration dated 7/5/24, indicated All nurses must possess an awareness of responsibility to follow physician's orders precisely . Review of facility policy entitled Sliding Scale Insulin Coverage dated 7/5/24, indicated Nurse verifies type and amount of insulin to be given, and administers it. and Nurse will record in the EMAR the date, time, fingerstick blood sugar level and the amount of insulin administered. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included Diabetes (a health condition that caused by the body's inability to produce enough insulin), Hypertension (high blood pressure), and Hemiplegia (a condition where a person is paralyzed and unable to move one side of their body). Review of Resident R1's physician's orders revealed an order dated 4/9/24, for Insulin Lispro (medication to treat diabetes and control blood sugar levels) 100 Units per Milliliter Subcutaneous (an injection placed just under the skin) four times a day for sliding scale (a scale to determine how much insulin to give based on the blood glucose results) 70-130 0 units, 131-180 1 unit, 181-240 = 2 units, 241-300 3 units, 301-350 4 units four times a day for diabetes. Review of Resident R1's September 2024, and October 2024, Medication Administration Record's (MAR) revealed Resident R1's Blood Glucose Monitoring (BGM) at breakfast on 9/18/24, was 161 and documentation on the MAR was 0 for insulin given. Review of MAR's for Hour of Sleep (HS) on 9/11/24, BGM was 211; on 9/18/24, BGM was 242; on 9/19/24, BGM was 240; on 9/25/24, BGM was 271; and on 10/16/24, BGM was 337. The MAR's lacked documentation of the amount of insulin administered in accordance with the physician's order. Interview with the Director of Nursing on 10/30/24, at 1:00 p.m. confirmed that Resident R1's Insulin Lispro was not administered in accordance with physician's orders. He/she also confirmed that Resident R1's insulin should have been administered in accordance with the physician's order. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer routine oxygen as ordered for one of 18 residents reviewed (Resident R31). Findings include: Review of facility policy entitled Medication Administration dated 7/5/24, indicated All nurses must possess an awareness of responsibility to follow physician's orders precisely . Review of Resident R31's clinical record revealed an initial admitted [DATE], with diagnoses that included malignant neoplasm of the right bronchus or lung (lung cancer), atrial fibrillation (irregular heartbeat), and low back pain. Resident R31's clinical record revealed a physician's order dated 7/31/24, indicating Resident R31 was to be on routine oxygen set at 2 liters per minute via nasal canula. Resident R31's Medication Administration Record (MAR) for September 2024 and October 2024 revealed that he/she did not have his/her routine oxygen in place as ordered by the physician on every shift on 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, 9/30/24, 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24, 10/9/24, 10/10/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/16/24, 10/17/24, 10/18/24, 10/19/24, 10/20/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/26/24, 10/27/24, 10/28/24, and 10/29/24. During an interview on 10/30/24, at 1:43 p.m. Licensed Practical Nurse Employee E3 confirmed that Resident R31's routine oxygen order was not being administered as ordered by the physician on the shifts and dates listed above. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility records and staff interview, it was determined that the facility failed to assure required attendance of the Medical Director to Quality Assurance and Performance Improvement (QAPI) Committee meetings for one of four quarterly QAPI Committee meetings (September 2024). Findings include: A facility policy entitled Quality Assurance and Process Improvement (QAPI) Program and Committee dated 7/5/24, indicated the QAPI committee shall meet at least quarterly and will include feedback from the Medical Director. Review of the QAPI Committee Attendance Records from April 2024 through October 2024 revealed no evidence on the attendance sign-in sheets for the required QAPI meetings that the Medical Director was in attendance for the September 2024 meeting. During an interview on 10/31/24, at 11:13 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that the Medical Director attended the quarterly QAPI Committee meeting as required for the September 2024 meeting. 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interview, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter One of 2024). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). First quarter reporting includes data from October 1st through December 31st. Review of PBJ staffing data reports for fiscal year first quarter 2024 revealed the facility triggered for No RN hours on 12/17/23, 12/23/23, 12/24/23, 12/25/23, and 12/31/23, and Failed to have Licensed Nursing Coverage 24 hours/day on 12/16/23, 12/17/23, 12/23/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23. Review of staffing documentation on 12/17/23, 12/23/23, 12/24/23, 12/25/23, and 12/31/23, revealed the facility did have RN hours and on 12/16/23, 12/17/23, 12/23/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23, the facility did have Licensed Nursing Coverage 24 hours/day, indicating the facility failed to submit accurate PBJ information as required by the ACA. During an interview on 10/31/24, at 10:41 a.m. the Scheduler Employee E2 confirmed that the PBJ report for Quarter One for 2024 was submitted inaccurately. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure staff completed all required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from December 2022 through November 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from December 2022 through November 2023, was provided for review. During an interview on 11/02/23, at 12:40 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(d) Staff development

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a homelike dining experience by not having the dining room open for all residents to use for breakfast, lunch and dinner. Findings include: Review of the facility policy entitled, Elder Dining Options dated 11/16/22, revealed that the facility offers several dining options: supervised dining in the Kallimos Cafe (Main Dining Room), supervised dining in the Elder's room, supervised dining in the Fig Street Common Area and assisted dining in the Elder's room. Observations of meals served to all residents' rooms from 10/30/23, through 11/01/23, revealed that the dining room had not been open for the resident population to use for each meal (breakfast, lunch and dinner). Review of the dietary staff schedules dated from 8/27/23, through 11/02/23, revealed that the dining room had only been open five times during that 68 day period. During an interview on 11/01/23, at 1:15 p.m. the Nursing Home Administrator confirmed the residents have been eating in their rooms or common areas and have not been allowed to eat in the Kallimos Cafe consistently for the past several months. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility records, observations, and resident, family member, and staff interviews, and review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for six of 21 residents reviewed (Residents R9, R36, R40, R44, R47, and R53). Findings include: Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Section GG0100 Prior Functioning: Everyday Activities. Indicate the resident's usual ability with everyday activities prior to the current illness, exacerbation, or injury. Review of Resident R47's MDS information identified a BIMS of 14/15 and was Dependent (helper does All of the effort Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity), During resident interviews on 10/30/23, from 11:00 a.m. through 3:30 p.m., Resident R47 verbalized that call bell response times were a concern with wait times of an hour or more. Resident R47 indicated that he/she has to wait for assistance to go the bathroom and his/her incontinence product is typically soaked by the time staff answer his/her call light. Resident R47 also indicated it was common to wait for long periods regardless of shifts. Resident R53, with a BIMS of 11/15, verbalized that he/she would like to go to the dining room for meals. However, due to not enough staff, the dining room is not open, and residents are required to eat each meal in their rooms. Resident R47 and Resident R53 verbalized that meals are late. Observations on 10/30/23, 10/31/23, and 11/01/23, revealed the dining room was not open for resident meals. During a Resident Council meeting on 10/31/23, at approximately 10:15 a.m., four of six residents (Resident R9 with a BIMS 15/15, R36 with a BIMS 15/15, R40 with a BIMS 15/15, and R44 with a BIMS 15/15) in attendance indicated resident needs were not being met due to long call bell response times related to insufficient staffing. During an interview on 11/02/23, at 11:20 a.m. the Director of Nursing confirmed the dining room has not been open and off shifts (afternoon and midnight shift) have been a struggle to meet the resident needs due to insufficient staff. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(4) Nursing services

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide urostomy (an opening in the belly made during surgery to re-direct urine away from the damaged bladder) care and services consistent with professional standards of practice for one of one residents with a urostomy (Resident 57). Findings include: Upon request, no facility policy was provided by the Director of Nursing (DON). Review of Resident 57's clinical record revealed an admitted [DATE], with diagnoses of kidney failure, chronic kidney disease-stage four (kidneys are severely damaged and are not able to filter waste from the blood sufficiently), gastro-esophagus reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), and an artificial opening of the urinary tract (urostomy). Review of Resident R57's care plan dated 10/13/23, identified an alteration in elimination as shown by the presence of a urostomy with interventions to change appliance per order. Review of Resident R57's physician order referenced on the Treatment Record, dated with a start date of 1/23/20, revealed Change urostomy Q [every] 3 days - Every 72 hours Apply ring of stoma [artificial opening] paste at opening . Review of the Resident R57's Treatment Record for October 2023 from 10/01/23, through 10/31/23, revealed Resident R57's urostomy was only changed on 10/01/23, 10/10/23, 10/20/23, and 10/22/23, or four of 31 days. Observations of Resident R57 on 10/30/23, at approximately 11:00 a.m., on 10/31/23, at approximately 10:00 a.m., and on 11/01/23, at approximately 1:00 p.m. revealed Resident 57 with a urostomy maintained. A strong odor of urine was also noted during the observations. During an interview on Tuesday, 10/31/23, at approximately 11:00 a.m. Resident 57 indicated that his/her urostomy does not get changed as ordered on Tuesdays and Saturdays weekly. Furthermore, an interview on Wednesday, 11/01/23, at approximately 1:00 p.m. revealed Resident 57's urostomy did not get changed the day prior, 10/31/23, as ordered. During an interview on 11/01/23, at 2:45 p.m. the DON confirmed that Resident R57's urostomy was not changed every three days per the physician order as noted above and failed to provide urostomy care and services consistent with professional standards of practice for Resident 57. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly label multi-use pens of insulin with an opened and/or use by dates for one of three medication storage carts reviewed (Birch Street). Findings include: Review of the current facility policy entitled, Insulin Administration Procedure, last reviewed 11/13/2022, identified that Upon opening a new vial, make sure to write both the open and discard date on the vial with a permanent marker. Timing and loss of potency varies depending on the type of insulin, refer to the pharmacy label prior to writing discard date. Observation of medication storage cart on Birch Street, on 10/30/2023, at 3:45 p.m. revealed that multi-use pens of insulin were opened with no opened date and/or use-by date printed on the vial. During an interview with Licensed Practical Nurse Employee E1 on 10/30/2023, at the time of the observation, it was confirmed that the multi-use pens of insulin were opened and in the medication cart for use and there was no opened date and/or use-by date on the pens for staff to know if the medication was still safe for use or to discard. During an interview on 10/30/2023, at 3:45 p.m. Registered Nurse Supervisor Employee E2 confirmed that insulins in the Birch Street cart were opened with no opened date and/or use by date on the pens. It was confirmed that opened pens of insulin should have opened and/or use by dates on the pens. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate direct staff supervision as indicated on resident's plan of care summary related to going outside to the pond in their motorized wheelchair which resulted in actual harm of left femur fracture, a broken nose, and left hand and arm bruising and swelling. This failure presented an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). Findings include: A review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses of stroke, congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles which may result in fatigue and shortness of breath), and [CONDITION(S)] (heart disease resulting in irregular heart beat). A review of Resident R1's current plan of care summary revealed I have a history of falls with risk of additional falls related to altered mobility, [CONDITION(S)], [CONDITION(S)] medication, and requires assistance with all aspects of care. Intervention implemented 2/26/20, included Please make sure that I have Walkie talkies when I go outside on my power w/c (wheelchair) and frequent checks while outside. Intervention implemented 5/26/20, included I enjoy fishing at the pond, please go with me to the pond and stay with me for the duration of the activity by the pond. A review of nursing progress notes dated 5/21/22, revealed .elder flipped his overcharge [motorized wheelchair] at the pond at 1335 (1:35 p.m.). This author and RN supervisor to the pond and elder seen in pond with staff member holding his head and shoulders up, elders overcharge next to him tipped over in the pond. Elder c/o (complained of) bilateral leg pain, had right leg crossed over the left leg, left hand and arm swelling and bruising with skin tear to hand, abrasion to forehead and apparent hematoma present. Bruising forming to left eyelid area. 911 called . During an interview on 5/24/22, at 9:40 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R1 is to take a Walkie-talkie with him/her when they go outside in his/her motorized wheelchair and that if Resident R1 goes to the pond he/she is to have direct staff supervision. During an interview on 5/24/22, at 11:40 a.m. Nurse Aide (NA) Employee E2 confirmed Resident R1 is to take a Walkie-talkie with him/her when they go outside in his/her motorized wheelchair so that he/she can communicate with staff if needed. NA Employee E2 stated that if Resident R1 goes to the pond he/she is to have direct staff supervision. During an interview on 5/24/22, at 1:07 p.m. LPN Employee E3 confirmed Resident R1 is to take a Walkie-talkie with him/her when they go outside in his/her motorized wheelchair and that on the day of the incident (5/21/2022) the Walkie-talkies were not charged and Resident R1 went outside without them at 11:45 a.m. LPN Employee E3 stated he/she checked on Resident R1 around 12:45 p.m. and encouraged him/her to come into the facility for rest and a drink as it was a hot and humid day. When asked where Resident R1 was when LPN Employee E3 checked on him/her at 12:45 p.m. LPN Employee E3 stated he/she was down at the pond. LPN Employee E3 stated Resident R1 was educated on not being down at the pond without staff supervision and he/she was escorted back to the facility. LPN Employee E3 stated he/she entered the facility through the door to Ash Unit and Resident R1 was either going to enter through Fig door or the front door. LPN Employee E3 returned to his/her assigned unit to continue performing job duties. At approximately 1:35 p.m. NA Employee E4 found another set of Walkie-talkies that were charged and stated he/she was going to take them out to Resident R1. LPN Employee E3 informed NA Employee E4 to check with the receptionist first to see if Resident R1 was in the building or on the porch as he/she was supposed to come in at 12:45 p.m. to get a drink and rest. NA Employee E4 phoned the receptionist who reported he/she had not seen Resident R1 come back into the facility and he/she was not on the front porch. NA Employee E4 then went outside to look for Resident R1, heard him/her yelling and found him/her in the pond. When asked where the motorized wheelchair was, LPN Employee E3 stated it was also in the pond. The facility failed to ensure Resident R1 had adequate supervision while outside and knowing that Resident R1 was already found by the pond the facility failed to provide direct supervision or ensure Resident R1 came back into the facility as Resident R1 indicated he/she would and ensure the Walkie-talkies were charged and available for Resident R1 to take outside with him/her. On 5/24/22, at 3:35 p.m. the Nursing Home Administrator (NHA) Assistant Director of Nursing (ADON), Director of Operations, and Regional NHA were made aware that Immediate Jeopardy existed for one of six Residents in the facility and that a corrective action plan was required. On 5/24/22, at 6:19 p.m. an acceptable corrective action plan was approved which included the following interventions: 1. Implementing policy where by no resident will use motorized wheelchair or scooters outside the facility unless they have supervision. Accommodations will be made to ensure resident continue to have the ability to go outside when requested including offering the use of the secured courtyard. 2. Provide education to all residents who utilize motorized wheelchairs / scooters, and all staff of the new policy. Care plans will be updated indicating need of supervision outside of the facility for those who use motorized wheelchair and/or scooters. 3. Education will be substantiated by new policy review and signature of understating of this policy. 4. All residents in the facility who have power chairs were reviewed to determine who of them have power wheelchair / scooters and care plans were updated to include supervision per policy. 5. This issue will be brought to the Quality Assurance Performance Improvement committee for review and follow up until the plan of correction. On 5/25/22, between 11:00 a.m. and 12:53 p.m. observations, review of clinical records, resident and staff interviews, and review of policy and staff education confirmed the facility implemented the above stated action plan. On 5/25/22, at 1:17 p.m. NHA and ADON were informed that the Immediate Jeopardy had been lifted. 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 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, clinical and facility records, observations, and staff interviews, it was determined that the facility failed to provide adequate assistance to protect a resident from injury during a transfer with a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling) that resulted in actual harm when the resident suffered a fracture of the cervical spine and a three centimeter (cm) laceration to the posterior (back) head for one of one residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Transfer and Mobility Guidelines, dated 6/20/20, stated On admission, all Elders are assessed by the therapy care partners to determine ambulation status and the amount of assistance required for transfers. The assessor documents the transfer/mobility guideline on the Elder's care plan, located on the back of each Elder's door. If the nursing care partner feels an Elder's lifting requirement has decreased below the level indicated on the Care Plan, the care partner should continue using the current level of assistance AND request an assessment from Therapy. The policy also stated, TWO care partners are required throughout the entire lift procedure any time a Journey/Maxi lift [mechanical lift] is used. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included [CONDITION(S)] with behavioral disturbance (disease of the brain that affects decision making and mood), major depressive disorder, spinal stenosis (narrowing of the spaces within the spine), and dizziness. Review of Resident's R1's Minimum Data Set (MDS - periodic assessment of resident care needs), dated 1/14/22, revealed Resident R1 had severe cognitive impairment and required extensive assistance of two staff persons with physical assist for transfers. Review of Resident's R1's care plan, dated 5/22/20, indicated the resident's transfer status was a total assist with use of Maxi Lift and two assist. The care plan was observed on the back of Resident R1's door during unannounced visit to the facility on [DATE]. Review of Resident's R1's interdisciplinary notes dated 2/16/22, at 8:06 p.m. revealed RN (Registered Nurse) Supervisor and Licensed Practical Nurse (LPN) at 3:05 p.m., both heard a fall and screams coming from Resident R1's room. Upon arrival, Resident R1 was laying on the floor with head resting in blood on the leg of a Maxi lift following a fall out of the lift. Nursing Assistant (NA) Employee E1 had witnessed the fall as indicated in their report of the Maxi lift malfunctioning when NA operated it to move the resident back into the bed. Resident R1 was assessed by RN Supervisor then transferred via ambulance to the hospital. Review of Resident's R1's interdisciplinary notes dated 2/16/22, at 9:53 p.m. revealed at 7:45 p.m. resident returned to facility with six staples to laceration on posterior head. A hospital radiology report dated 2/16/22, disclosed that Resident R1 had a Computed axial Tomography (CT) of the cervical spine, which diagnosed the resident with an acute fracture of the spinous process of C7 (cervical spine). Review of a facility incident report and fall investigation worksheet dated 2/16/22, revealed the facility investigation's immediate results as most likely cause of Resident R1's fall was due to a one person transfer with the Maxi lift, also noted as incorrect usage of lift, resulting in a laceration of head and fracture of spine. A review of the facility's investigation revealed that NA Employee E1 confirmed on 2/16/22, he/she used a mechanical lift (Maxi lift) while transferring Resident R1 to a Geri-chair from bed for a bath with no one else present. NA Employee E1 stated, During transfer, staff was turning lift towards chair. Elder [Resident R1] swung left arm around outside of lift pad and the buckle came off and [Resident R1] fell on the floor. Resident hit back of his/her head. NA Employee E1 admitted he/she did not follow Resident R1's care plan and did not request assistance with the mechanical lift transfer. During an interview on 2/23/22, at 3:20 p.m. the Director of Nursing confirmed that NA Employee E1 transferred Resident R1 incorrectly causing a fracture of the spine and head laceration. The facility failed to provide Resident R1 a safe transfer which resulted in actual harm of a three centimeter laceration to the posterior head and a fracture of the C-7 cervical spine. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical and facility records, observations, and staff interviews, it was determined that the facility failed to ensure residents were free from neglect during care with the use of a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling) that resulted in actual harm of a fracture of the cervical spine and a three centimeter (cm) laceration to the posterior (back) head for one of one residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Elder Abuse, dated 8/20/20, stated Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate and appropriate services, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy entitled, Transfer and Mobility Guidelines, dated 6/20/20, stated On admission, all Elders are assessed by the therapy care partners to determine ambulation status and the amount of assistance required for transfers. The assessor documents the transfer/mobility guideline on the Elder's care plan, located on the back of each Elder's door. If the nursing care partner feels an Elder's lifting requirement has decreased below the level indicated on the Care Plan, the care partner should continue using the current level of assistance AND request an assessment from Therapy. The policy also stated, TWO care partners are required throughout the entire lift procedure any time a Journey/Maxi lift [mechanical lift] is used. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident's R1's Minimum Data Set (MDS - periodic assessment of resident care needs), dated 1/14/22, revealed Resident R1 had severe cognitive impairment and required extensive assistance of two staff persons with physical assist for transfers. Review of Resident's R1's care plan, dated 5/22/20, indicated resident's transfer status as a total assist with use of Maxi Lift and two assist. The care plan was observed on the back of Resident R1's door during unannounced visit to the facility on [DATE]. Review of Resident's R1's interdisciplinary notes dated 2/16/22, at 8:06 p.m. revealed RN (Registered Nurse) Supervisor and Licensed Practical Nurse (LPN) at 3:05 p.m., both heard a fall and screams coming from Resident R1's room. Upon arrival, Resident R1 was laying on the floor with head resting in blood on the leg of a Maxi lift following a fall out of the lift. Nursing Assistant (NA) Employee E1 had witnessed the fall as indicated in their report of the Maxi lift malfunctioning when NA operated it to move the resident back into the bed. Resident R1 was assessed by RN Supervisor then transferred via ambulance to the hospital. Review of Resident's R1's interdisciplinary notes dated 2/16/22, at 9:53 p.m., revealed at 7:45 p.m. resident returned to facility with six staples to laceration on posterior head. A hospital radiology report dated 2/16/22, disclosed Resident R1 had a Computed axial Tomography (CT) of the cervical spine, which diagnosed the resident with an acute fracture of the spinous process of C-7 (cervical spine). Review of a facility incident report and fall investigation worksheet dated 2/16/22, revealed the facility investigation's immediate noted results as most likely cause of Resident R1's fall was due to a one person transfer with the maxi lift, also noted as incorrect usage of lift, resulting in a laceration of head and fracture of spine. A review of the facility's investigation revealed that NA Employee E1 confirmed on 2/16/22, he/she used a mechanical lift (Maxi lift) while transferring Resident R1 to a Geri-chair from bed for a bath with no one else present. NA Employee E1 stated, During transfer, staff was turning lift towards chair. Elder [Resident R1] swung left arm around outside of lift pad and the buckle came off and [Resident R1] fell on the floor. Resident hit back of his/her head. NA Employee E1 admitted he/she did not follow Resident R1's care plan and did not request assistance with the mechanical lift transfer. The fall investigation also revealed NA Employee E2's statement dated 2/16/22, which indicated NA Employee E1 was undressing elder to take to shower. NA Employee E2 inquired if NA Employee E1 needed help with NA Employee E1's response .I got it so NA Employee E2 left room to pick up meal trays but told NA Employee E1 to call if he/she needed help. NA Employee E1 did not get/request help with transfer. During an interview on 2/23/22, at 3:20 p.m. the Director of Nursing (DON) confirmed that NA Employee E1 transferred Resident R1 incorrectly that resulted in a fracture of the spine and head laceration. The DON confirmed that NA Employee E1 knowingly transferred Resident R1 incorrectly. The DON confirmed NA Employee E1 did not ask for assistance when using the Maxi lift which required two people assist. The DON confirmed that NA Employee E2 left Resident R1's room to pick up trays just prior to when the fall with injury occurred. The facility failed to ensure that Resident R1 was free from neglect which resulted in actual harm of a three centimeter laceration to the posterior (back) head and a fracture of the C-7 cervical spine from a fall from a mechanical lift. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services