Every finding on record at Rydal Park of Philadelphia Presbytery Homes, Inc

Based on review of clinical records and interview with staff and resident, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for one of six residents reviewed for pain management (Resident R1).Findings Include: Review of Resident R1's clinical record revealed that R1 was admitted to the facility on [DATE], with diagnoses of generalized abdominal pain, pain unspecified, hemorrhoids (rectal veins), interstitial pulmonary disease (lung fibrosis), bilateral carpal tunnel syndrome (wrist neuropathy), abrasion of the left breast, initial encounter (breast scrape), pruritus (itching), rheumatoid arthritis (inflammatory arthritis), and cervical spinal stenosis (neck stenosis). Review of Resident R1's clinical record revealed a physician's order dated March 24, 2026, for Morphine Sulfate (Concentrate) Oral Solution 100 mg/5 ml, to give 0.75 ml by mouth every 4 hours as needed for pain rated 3-7/10 (0.75 ml = 15 mg). On July 14, 2026, at 10:27 a.m., an interview was conducted with Resident R1, who reported that medications are not being administered timely. For example, the last time Resident R1 received his/her morphine was yesterday morning, July 13, 2026, because the facility was out of morphine. Resident R1 stated that he/she is supposed to receive morphine per physician's order every 10 days. One of the nurses had notified management that Resident R1's supply of morphine was running low, but the facility failed to order it ahead of time. Yesterday, Resident R1 received a prescription for morphine from the physician, and per his/her preference, she/his asked her spouse to go to the local pharmacy to fill it; however, the local pharmacy was out of morphine. The last dose Resident R1 received was yesterday morning. On July 14, 2026, at 11:35 p.m., an interview with the DON, E2, confirmed that a review of Resident R1's Controlled Medication Utilization Record indicated that R1 received 0.05 ml on July 14, 2026, at 6:30 a.m., administered by licensed nurse E4 as the last documented dose. E2 further reported that the pharmacy delivered Resident R1's morphine 100 mg/5 ml early on July 14, 2026, between approximately 5:00 a.m. and 6:00 a.m. However, according to the DON, it is most likely that Employee E5 did not check the medication drop-off, and Resident R1 did not receive the full ordered dose of 0.75 ml but instead received 0.5 ml. A review of the Medication Administration Record (MAR) revealed that Resident R1 had a pain level of 9 documented on July 14, 2025, and received 0.5 ml of morphine at 6:20 a.m. On July 14, 2026, at 11:35 p.m., an interview with the Unit Manager, Employee E3, revealed that licensed nurse E4 was not available for interview because she had completed the 11:00 p.m. to 7:00 a.m. night shift. Employee E3 confirmed that the pharmacy delivered Resident R1's medication, Morphine 100 mg/5 ml, early on July 14, 2026. Employee E3 brought the sealed, unopened bottle of Morphine 100 mg/5 ml and the Controlled Medication Utilization Record, which had not been signed out. Employee E3 reported that most likely Employee E4 did not check the nursing office to see that the medication was available and administered 0.05 ml of morphine instead of the ordered 0.75 ml. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observation, clinical record review, review of facility documentation, and resident and staff interview it was determined that the facility failed to ensure that call bells were answered in a timely manner for two of six residents reviewed (Resident R1 and R6).Findings include:A review of the facility policy titled, Answering Call Light last revised November 2022 revealed, the purpose of the this procedure is to ensure timely responses to the residents request and needs. On July 14, 2026, at 10:23 AM, an interview was held with Resident R1. R1 reported that he/she does not allow staff to turn off the call bell if he/she has not yet been assisted, as the facility has a pattern of staff turning off the call bell, promising to return to provide support, and then not returning. Resident R1 also reported that on Saturday, July 11, 2026, his/her call bell was activated at approximately 2:15 PM and was not answered until 3:15 PM. On July 14, 2026, at 10:45 AM, an interview was held with Resident R6, who is also the new President of the Resident Council. R6 reported that sometimes call bells are not answered within a reasonable amount of time. R6 stated that the last time his/her call bell was not answered was last week. Resident R6 pressed the call bell during the evening shift after dinner because he/she wanted to get into bed. The call bell was not answered, and R6 was unable to recall how long it took for staff to respond. On July 14, 2026, at 12:23 PM, a review of the call bell report was conducted with the Administrator (E1) and the Director of Nursing (E2). They confirmed the following: On Sunday, July 12, 2026, Resident R6's call bell rang at 12:45 PM and was not answered for 59 minutes and 1 second.On July 11, 2026, it rang at 6:41 PM and was not answered for 35 minutes and 40 seconds.On July 10, 2026, it rang at 10:32 AM and was not answered for 25 minutes and 54 seconds.On July 9, 2026, it rang at 6:15 PM and was not answered for 35 minutes and 25 seconds.On Wednesday, July 8, 2026, it rang at 9:31 AM and was not answered for 31 minutes and 30 seconds.On July 7, 2026, it rang at 2:03 PM and was not answered for 30 minutes and 9 seconds. Further review of the call bell report showed: On June 10, 2026, Resident R1's call bell was activated at 8:30 AM and was not answered for 122 minutes and 20 seconds.On July 10, 2026, it was activated at 11:02 AM and was not answered for 26 minutes and 59 seconds.On July 11, 2026, it was activated at 6:11 AM and was not answered for 26 minutes and 40 seconds. During this same review, the Nursing Home Administrator confirmed that the call bell system failed to ensure that call bells were answered in a timely manner. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area. Findings include: A tour of the Food Service Department was conducted was conducted with the Food Service Director (FSD), Employee E3, on March 3, 2025, at 9:43 a.m., revealed the following concerns: Observations in the receiving area revealed two grey trash cans and one blue dumpster of trash inside exposed. Observations near the receiving door revealed four wooden pallet stacks with broken pieces, laying on the ground, approximately five feet high, three broken wooden cabinets, and broken bathroom vanity. Interview with the FSD on March 3, 2025, at 9:55 a.m. confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Production, Purchasing, Storage revised January 1015 revealed that, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Further review revealed staff must date and rotate items; first in, first out (FIFO) and discard food past the use-by or expiration date. A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E3, on March 3, 2025, at 9:43 a.m. The refrigerator emitted a foul sulfur odor. Observations in the refrigerator revealed an open package of ground beef was labeled with an expiration date of February 22, 2025. Further observations revealed two 10-pound cooked, ready to eat pastrami was labeled January 17, 2025. Further observations revealed eleven 10-20-pound beef hunks were undated and unlabeled; and four 10-pound beef briskets were unlabeled and undated. Further observations revealed eight 10- pound lamb hunks were labeled good through 2/19 and placed in a tall metal container. The container was filled with red colored liquid covering the lamb hunks. Further observations revealed five 10-20- pound pork loins undated and unlabeled; two top round roast beef contained no received date. Interview with the FSD during the kitchen tour confirmed the above-mentioned findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R67 and Resident R57) Findings include: Review of Medication Administration General Guidelines dated May 2016, revealed that Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal and vaginal medications. On March 6, 2023, at 9:26 a. m., observed a medication administration, dispensed by a Registered Nurse, Employee E9, to Resident R396. It was observed that Licensed nurse, Employee E5 prepared the medication, including the eye drop, placed the medication next to the resident. Employee E9 touched resident's bed side table. Once the nurse administered the oral medications, he opened an eye drop and administered the eye drop to the resident. It was observed that the employee did not was his hand or wear gloves prior to the eye drop administration. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on review of clinical record, review of facility documentation and review of facility policy, it was determined that the facility failed to ensure that a resident was transfer into bed timely as prefer by the resident for one of 21 residents sampled residents for activities of daily living (Resident R246). Findings Include: Review the policy title Activates of Daily Living (ADLs), supporting that was revised on March on 2018, revealed that on residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) Review of Resident R246's Minimum Data Set (MDS- assessment of resident's needs) dated January 6, 2025 revealed that the resident had a BIMS (Brief Interview of Mental Status) of 14, which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident was able to chose her/his own customary preferences and the residnet required partial to moderate assistance for bed mobility. Review faciltiy investigation initiated on January 7, 2025, revealed that the resident reported to the Social Worker that on January 7, 2025, that after lunch the team member who help her to the bathroom refused to put her in bed when she requested to go to bed. Reviewed the witness statement from nursing aide, Employee E5 (7-3 pm day shift), from January 7, 2025, revealed that resident R246 asked to go to the bed around 3:02 p.m. yesterday. ask her can she wait for the other shift. Reviewed another witness statement from Register nurse, Employee E6 (3-11pm evening shift) of January 7, 2025, revealed that Employee E7 went into room to resident R246 and the resident reported that she asked earlier to be put into bed after she went to the bathroom and the person refused to take her to the bed.Resident stated that the aid told her to wait after dinner .the agency aide took her to the bathroom around 6:27 p.m. The facility failed to ensure that Resident R246 was assisted into bed timely. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246) Findings include: Review of nursing note for Resident R1, dated August 24, 2024, revealed that the resident was discharged to the hospital for shortness of breath. Review of nursing note for Resident R59, dated October 27, 2024, revealed that the resident was discharged to the hospital for evaluation and treatment. Another nursing note for Resident R59, dated November 12, 2024, revealed that the resident was discharged to the hospital for shortness of breath. Further review revealed a nursing note for Resident R59, dated December 28, 2024, which indicated that the resident was discharged to the hospital with diabetes ketoacidosis (complication of diabetes). Another nursing note for Resident R59, dated February 18, 2024, indicated that the resident was discharged to the hospital with Hypoxia (body deprived of adequate oxygen supply at the tissue level). Review of nursing note for Resident R246, dated February 11, 2025, revealed that the resident was sent to the hospital for evaluation. Further review of clinical records revealed that there was no documented evidence that the Resident and Residents' representative were provided with a written notice of the facility bed-hold policy at the time of facility-initiated transfer to the hospital for Resident R1, R59, and R246. Interview with the Nursing Home Administrator, Director of Nursing, on March 5, 2025, at 2:46 p.m. confirmed that Resident R1, R59, and R246, and resident representatives were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return to a bed at the facility. Further interview confirmed that there was no system in place to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital. 28 Pa Code 201.14(a) Responsibility of licensee 28 PA Code 201.29(f) Resident rights

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246) Findings Include: Review of nursing note for Resident R1, dated August 24, 2024, revealed that the resident was discharged to the hospital for shortness of breath. Review of nursing note for Resident R59, dated October 27, 2024, revealed that the resident was discharged to the hospital for evaluation and treatment. Another nursing note for Resident R59, dated November 12, 2024, revealed that the resident was discharged to the hospital for shortness of breath. Further review revealed a nursing note for Resident R59, dated December 28, 2024, which indicated that the resident was discharged to the hospital with diabetes ketoacidosis (complication of diabetes). Another nursing note for Resident R59, dated February 18, 2024, indicated that the resident was discharged to the hospital with Hypoxia (body deprived of adequate oxygen supply at the tissue level). Review of nursing note for Resident R246, dated February 11, 2025, revealed that the resident was sent to the hospital for evaluation. Review of clinical record revealed no evidence that Residents R1, R59, and R246 representatives were notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Interview with the Nursing Home Administrator, Director of Nursing, on March 5, 2025, at 2:46 p.m. confirmed that the residents' representatives were not notified of the hospital transfers and the reasons for the transfers in writing, and in a language and manner they understood. Further interview confirmed that there was no system in place regarding notifying the residents representatives, in writing, including the reasons, prior to resident transfer or discharge. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of five residents reviewed for medication safety (Resident R80). Findings include: Review of the facility policy Self-Administration By Resident dated November 2017, indicates Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process Review of Resident R80's physician order dated February 15, 2025, revealed an order for Timolol Maleate Ophthalmic Solution 0.5 % instill 1 drop in both eyes every morning and at bedtime for glaucoma. Observation of Resident R80 on March 6, 2025, at 9:17 a.m. with Employee E9, Registered Nurse, revealed that the resident had a bottle of Timolol Maleate Ophthalmic Solution 0.5 % sitting on her over the bed table. Resident R80 stated she kept the eye drop on the bed side table or on the over bed table. Resident stated she did not keep it in a locked storage. Interview with the Employee E9, Registered Nurse on March 6, 2025 stated Resident R80 self administers the eye drops and there should be an assessment for medication administration safety. Review of Resident R80's assessments on March 6, 2025, did not to include an assessment for medication self-administration. Interview with the Employee E6, Registered Nurse on March 6, 2025 confirmed that there was no medication self-administration assessment for Resident R80. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.9(a)(1) Pharmacy services.

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for one of six residents reviewed for psychotropic medications (Residents R396). Findings include: Review of Resident R396's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 9, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including progressive neurological conditions and Parkinson's disease. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated that the resident was moderately cognitively impaired. Review of progress notes for Resident R369 revealed a nurses note, dated December 24, 2024, which indicated that the resident had a new order for Seroquel (antipsychotic medication used to treat mood disorders). Review of Medication Administration Records (MARs) for Resident R369 revealed that the resident received Seroquel 12.5 milligrams (mg) daily from December 24, 2024, to December 30, 2024. The medication was increased to 25 mg daily on December 31, 2024. Further review of Resident R369's progress notes revealed no indication that the resident or her responsible party were notified of the new medication, that the risks and benefits were explained or that the resident was offered alternative treatment options. Review of Resident R369's psychiatry note, dated December 24, 2024, revealed that the resident had agitation and combative behavior and after adding long acting Sinemet (Medication to treat Parkinson's disease), previous Sinemet regimen was resumed, and Seroquel was added. There was no documented evidence in the psychiatric progress note that the risks and benefits were explained or that the resident was offered alternative treatment options. Interview on March 6, 2025, at 1:21 p.m. Employee E6, Nursing Supervisor, confirmed that there was no documentation available for review at the time of the survey to indicate that Resident R396 or their responsible parties were informed of their psychotropic medication addition, that the risks and benefits were explained or that they were offered alternative treatment options. 28 Pa Code 201.29(a) Resident rights 28 Pa code 211.2(d)(6) Medical Director

Based on facility documentation and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for 21 of 21 sampled residents. Findings include: Review of facility document titled, Arbitration Agreement revealed a designated signature area and two blank check boxes indicating whether the resident agrees to consent to arbitrate or do not consent to arbitrate. Further review revealed that resident signatures were present without indication of whether residents agree to arbitrate or disagree. Interview with the Facility Administrator, on March 6, 2025, at 10:00 a.m. revealed that facility staff failed to direct residents to mark which option they prefer and required a signature of the incomplete document. Further interview confirmed that a total of 204 residents arbitration records were incomplete. 28 Pa. Code 211.5(f) Medical records.

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate discharge notices were provided to the State Office of the Long-Term Care Ombudsman for two of five months reviewed (June and July 2024). Findings include: Review of emailed notifications sent to the office of the long term care ombudsman for the months of April, May, June, July, and August 2024, revealed that facility initiated emergency transfers and discharges for the months of June and July 2024, were not sent to the State Ombudsman until the date of the survey, September 24, 2024. Interview with the Executive Director, Employee E1, on September 24, 2024, at 4:00 p.m. confirmed that the notifications for June and July 2024 had not been sent to the State Ombudsman's office in a timely manner as required. 28 Pa. Code 201.18(b)(3) Management

Based on observation, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related to the processing of linens. Findings include: Observation at the Laundry room of the facility on May 6, 2024, at 9:34 a.m., revealed that one Laundry Aide, Employees E10, processing and folding clean linens for the use of residents, but letting the downward end of the linen dragging on the floor of the Laundry Room. At the time of the finding interviewed Employee E10, confirmed that the linen should have been folded without letting it drag on the floor of the Laundry Room, to prevent contamination and to maintain infection control. Observation at the Laundry room of the facility, on May 6, 2024, at 9:42 a.m., revealed that one Laundry Aide, Employees E12, was processing and folding clean linens for the use of residents, by holding the linens letting it to touch the Laundry Aides' personal clothing. At the time of the finding interviewed with Employee E12, confirmed that the linen should have been folded without letting it touch the employee's clothing to prevent contamination and to maintain infection control. 28 Pa Code 211.12 (d)(1)(5) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's medication regimen was free from potential unnecessary medications for one of five residents reviewed. (Resident R 72). Findings include: Review of Resident R72's clinical record revealed that Resident R72 was admitted to the facility December 1, 2020. Resident R 72 has diagnosis' including acute embolism and thrombosis of auxiliary vein (blood clots in the upper arm), Type 2 diabetes ((blood sugar or glucose is too high), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (condition marked by extreme anxiety or panic), malignant neoplasm of breast (metastatic breast cancer), and chronic diastolic heart failure (congestive heart failure). Review of Resident 72's clinical record revealed a physician order dated March 29, 2024, for Alprazolam (a psychotropic medication belonging to the class called benzodiazepine, is a fast acting tranquilizer used to treat anxiety disorders) 0.5 milligrams give one tablet by mouth every 8 hours as needed for anxiety. Review of Resident R72's MAR (Medication Administration Record), revealed that the resident received the medication Alprazolam on 4/5/2024, 4/12/2024, 4/14/2024, 4/19/2024, and 4/26/2024. Review of a pharmacy consultant review dated November 7, 2023 revealed a recommendation Per CMS regulations PRN (as needed) anxiolytic orders need a fourteen day stop date, however if a duration date greater then 14 days is needed, the order will need 1) a duration for use AND 2) a clinical rationale. Please include the duration for use and rationale for the following order: Alprazolam 0.5 mg PRN. Further review of this pharmacy consultant review revealed a nurses note that the medication Alprazolam was discontinued February 9, 2024, restarted March 23, 2024 and discontinued May 3, 2024. Review of clinical records revealed no evidence that the practitioner/ physician documented the rational and indicated the duration of the PRN order when the PRN order for Alprazolam was continued beyond 14 days. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of the facility policy, observation, and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of four medication carts observed (Middle Cart of Second Floor). Findings include: Review of the facility policy on Medication Labelling and Storage revised in February 2023; indicated; multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation of the Middle Cart of Second Floor, on May 6, 2024, at 10:31 a.m., revealed; the following opened eye medicines without marking any opened date on those medication vials: An opened 5 ML bottle of Tobramycin Ophthalmic Solution (used to treat eye infections), with expiry date, June 2025; two opened 15 ML bottles of [NAME] Tears Lubricant Eye Drop (used to dry eye), with expiry date, May 2026; an opened 5 ML bottle of Polymyxin B Sulfate and Trimethoprim Ophthalmic Solution (used to treat eye infection), with an expiry date of October 2025; an opened 5 ML bottle of Latanoprost Ophthalmic Solution (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision), with an expiry date of October 2025; an opened box of Systane Lubricant Eye drops Convenient single vials on the Go (used to treat dry eyes), with an expiry date of March 2025; and an opened 5 ML bottle of Brimonidine Tartrate/Timolol Maleate Ophthalmic Solution (used to treat high pressure inside the eye due to glaucoma), with an expiry date of September 2025. Interview with Registered Nurse (RN), Employee E9, at the time of the finding, confirmed; the eye drops bottles should have been discarded, as those eye drops vials had not been marked with the opened- dates, per the facility policy. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.9(g)(h) Pharmacy services 28 Pa Code 211.12(c) Nursing services 28 Pa 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for one four residents reviewed for nutritional status (Resident R39). Findings Include: Review of facility policy Weight Assessment and Intervention, revised March 2022, revealed undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change have been met. The evaluation includes, but not limited to, the resident's target weight range, and the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. Review of Resident R39's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 4, 2024, revealed the resident was admitted to the facility on [DATE], and had diagnoses of dementia and malnutrition. Review of Resident R39's nutrition assessment dated [DATE], by Registered Dietitian, Employee E3, revealed the resident was at risk for dehydration and development of pressure ulcers. Resident R39 was identified as underweight related to variable intakes, dementia, and need for assistance with meals. Weight goal for Resident R39 was identified as a range between 104 to110 pounds. Interventions included to monitor weight monthly/weekly. Review of Resident R39's weight history revealed the resident was weighed at 107 pounds on admission on April 2, 2024. Further review of Resident R39's weight trend revealed the resident was weighed at 99.8 pounds on April 10, 2024, and April 11, 2024, reflecting a significant weight loss of 6.7% and 7.2 pounds over 9 days. Resident R39 maintained a weight between 99.8 pounds and 100.4 pounds through April 24, 2024. Review of Resident R39's entire clinical record revealed no documented evidence the Registered Dietitian was made aware of the significant weight loss. Further review of Resident R39's clinical record revealed no documented evidence the Registered Dietitian monitored the resident's weekly weights and modified/reassessed the resident's needs consistent with the significant weight loss. Interview on May 3, 2024, at 11:45 a.m. with Registered Dietitian, Employee E3, confirmed Resident R39's significant weight loss was not assessed. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of facility policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident's wander guard was functioning for the resident who is at risk for elopement for one of the one resident reviewed (Resident R89 and failed to ensure hot beverage temperatures were monitored on one of three nursing units (3rd floor dining room). Findings include: Review of the facility Wandering and Elopements policy, last revised March 2019, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of Residents R89s clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of Alzheimer's diseases and unspecified dementia without behavioral disturbance, psychotic disturbance mood disturbance and anxiety. Review of Residents R89's quarterly MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated January 29, 2024, revealed Resident 89's BIMS score was 4 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 4 indicates that the resident's was cognitively impaired). A further review of the clinical record indicated that Resident R89 had a physician order dated March 20, 2024, check wanderguard (device place on wrist or ankle which automatically activates a locking mechanism system to lock doors when the resident approaches the exit doors) and proper placement every shift. A comprehensive care plan-initiated April 4, 2024, indicated The resident is an elopement risk r/t (related to) disoriented to place, impaired safety awareness. Under interventions further stated Device noted please monitor for function/placement and skin integrity impairment while device in use. On May 1, 2024, at 10:52 a.m. Resident R89 was observed wearing a wanderguard on his left wrist. A registered nurse, unit manager Employee E5 tried testing the wanderguard for functionality with the wanderguard testing equipment and it wasn't screening that the wanderguard was functioning. Resident R89 and Employee E5 walked towards the elevator to test the functionality of the device and the resident's wanderguard did not function to alert the staff that Resident R89 was exiting the nursing unit. Employee E5 confirmed that the wanderguard was not functioning and needed a replacement. Review of facility policy Safety of Hot Liquids, revised October 2014, revealed appropriate precautions will be implemented to maximize choice of hot beverages while minimizing the potential for injury. Further review of facility policy revealed appropriate interventions will be implemented to minimize the risk from burns such as maintaining a hot liquid serving temperature of not more than 180 degrees Fahrenheit. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Review of facility documentation revealed an in-service conducted for nursing staff for Heating of Food/Liquids dated 2/6/24 and 2/7/24. Review of in-service documentation revealed nursing staff may not reheat food for residents. Dietary is responsible to take temperatures. Observations on May 3, 2024, at 12:12 p.m. in the 3rd floor dining room revealed Dietary Aide, Employee E13, heating up a beverage in the microwave. Further observations revealed when the beverage was done in the microwave, Dietary Aide, Employee E13, took the mug out of the microwave and handed it back to the nurse aide without checking the temperature first. Subsequent interview on May 3, 2024, at 12:15 p.m. with Dietary Aide, Employee E13, confirmed the employee did not check the temperature of the water heated in the microwave before giving it back to the nurse aide for distribution to the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on a review of clinical records, review of facility policy and staff interviews, it was determined that the facility failed to follow physician orders related to congestive heart failure protocol for one of eight sampled residents (Resident R 72) to monitor resident's daily weights and notify the medical doctor if any weight gain. Findings include: Review of facility policy titled Heart Failure-Clinical Protocol revised November 2018, revealed that the physician identifies individuals with a history of heart failure and the nurse with assess and document. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, digoxin level, etc.) to monitor and when to report the finding to the physician. Review of Resident R72's clinical record revealed that Resident R72 was admitted to the facility on [DATE] with the diagnoses of acute embolism and thrombosis of auxiliary vein (blood clots in the upper arm), Type 2 diabetes (blood sugar or glucose is too high), hyperlipidemia (high cholesterol), hypertension (high blood pressure), anxiety (condition marked by extreme anxiety or panic), malignant neoplasm of breast (metastatic breast cancer), and chronic diastolic heart failure(congestive heart failure). Continued review of Resident R72's April and May 2024 physicians orders revealed an order to weigh daily for CHF (congestive heart failure) protocol, weigh resident before breakfast, notify MD (medical doctor) of weight gain of two pounds in twenty-four hours or five pounds in one week. Review of the resident's clinical record revealed no documented evidence that the resident was weighted daily before breakfast as ordered by the physician. Interview with Director of Nursing, Employee E2 on May 5, 2023, at 12:40 p.m. confirmed that the weights were not documented but believed that there was documentation elsewhere. The facility was no able to submit documentation related to daily weights obtained for Resident R72 for review. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of clinical records, review of facilitypolicy and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan related to respiratory care for one of 21 residents reviewed. (Resident R102) Findings include: Review of facility's policy 'Care Plans, Comprehensive Person-Centered,' indicates that the comprehensive, person-centered care plan will: 8 (e) describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of Residents R102's clinical record indicated admitted [DATE], with the diagnoses of encounter for screening for respiratory tuberculosis other specified symptoms and signs involving the circulatory and respiratory system, nasal congestion. A physician order dated April 18, 2024 revealed Ipratropium -Albuterol Solution 0.5-2.5 (3) Mg/ML Order summary 1 vial inhale orally two times a day for wheezing/chest congestion. Observation conducted on May 1, 2024, at 2:20 p.m. of Resident R102 revealed that the resident had a nebulizer machine next to his bedside. On May 3, 2024, at 9:47 a.m. an observation with a Director of Nursing, Employee E2 confirmed that Resident R103 has the nebulizer was receiving a active treatment during the observation. A review of the comprehensive care plan dated April 18, 2024, did not include a nebulizer treatment. Director of Nursing was able to confirm that the resident's comprehensive care plan was not revised to include the nebulizer treatment. 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure a complete and accurate investigation to rule out abuse for two bruises of unknown origin for one out of 28 residents reviewed (Resident R43). Findings include: Review of the facility policy, Elder Abuse Prevention, Identification, Response, Reporting, with a revision date of June 30, 2023 indicated that the identification of abuse, exploitation, neglect, mistreatment and misappropriation included witnessed events, resident or family report of abuse, verbal reports from other residents or family members, and injury of an unknown origin. Continued review of the policy indicated that the facility would respond to allegations or witnessed events by taking steps which included, protecting the resident and preventing further potential abuse, conducting a thorough investigation of the alleged violation, and reporting the alleged violation and investigation within required timelines. The policy also stated that allegations of abuse, exploitation, neglect or misappropriation of resident property investigation would include the assessment of the resident's immediate environment, review of the resident's assessment, and review of the resident's record. Review of the current plan of care for Resident R43 included the following diagnosis: anxiety (physical and mental response that occurs when the mind and body encounter stressful, dangerous, or unfamiliar situations); dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); constipation, and dysphagia (difficulty swallowing). Review of Resident R43's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's need) dated June 23, 2023 indicated that the resident was cognitively impaired. Review of a nursing note dated November 5, 2022 at 5:46 a.m. written by licensed nursing staff (Employee E16) indicated that the resident's nursing assistant (Employee E14) was completing morning care on the resident on November 5, 2022 when she noticed a bruise on the resident's forehead. Review of the nursing notes indicated that when Employee E16 assessed the resident , A quarter sized bruise was noted at the top right corner of the resident's head. When Resident R43 was asked to explain what happened, the resident stated, I don't remember when it happened, but I think it happened when I was driving my automobile. Review of information from the facility regarding the resident's referenced bruise included only one witness statement from the nursing assistant (Employee E14) who noticed the bruise during the 11:00 p.m. through 7:00 a.m. nursing shift while providing morning care to the resident. Review of a nursing note dated February 27, 2023 at 7:22 a.m. indicated that the nursing assistant assigned to Resident R43 reported to the licensed nursing staff (Employee E15) of a bruise that the nursing assistant noticied on the resident's right arm. Continued review of the nursing note indicated that upon Employee E15 assessing the resident, a medium sized bruise was on the resident's right arm. Review of a nursing note by licensed nursing staff (Employee E17) on February 27, 2023 at 12:18 p.m. indicated that the resident reported that she was unsure as to how the bruised occurred, but stated, but may have bumped it. Review of information from the facility regarding the resident's referenced bruise included only one statement from the nursing assistant who noticed the bruise during the 11:00 p.m. through 7:00 a.m. nursing shift. Review of the investigation regarding both referenced incidents where bruises of unknown origin were found on Resident R43 offered no other witness statement from staff members (e.g. nurses, nursing assistants, activity staff) on other shifts to see if any other staff members witnessed or heard anyting regarding Resident R43 during their work shift that may have aided the facility in ensuring a complete and through investigation to rule out resident abuse and/or neglect into the unknown origin of the resident's bruises that were found on the resident who is cogntively impaired. During an interview on July 13, 2023, at 11:45 a.m. with the Director of Nursing, and two Unit Mangers (Employee E5 and Employee E18), it was confirmed that no additional documentation regarding the interview of additional staff members on the same shift and previous shifts could be provided to show evidence that a complete and through investigation was completed to rule out neglect for Resident R43 who was found with two bruises of unknown origin on November 5, 2022 and February 27, 2023. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on review of closed clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent an elopement for one of five residents reviewed. This failure resulted in actual harm to Resident 318 who eloped from the facility and sustained a fall with a laceration to the forehead. (Resident 318) Findings include: Review of Resident R318's closed clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, unsteadiness on feet, generalized [CONDITION(S)] (wearing down of protective tissues of the bone), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and malignant neoplasm of frontal lobe (frontal lobe tumor - may cause behavioral and emotional changes). Review of Resident R318's nursing admission assessment dated [DATE], revealed that Resident R318 ambulated with assistance and was unsteady with walking and balance. Further review of the admission assessment indicated that Resident R318 was oriented x 2 (person and place) and presented with confusion. Review of Resident R318's nursing note dated January 17, 2021, at 2:00 p.m. revealed Resident wandered off the unit and sustained a fall. Review of nursing note dated January 17, 2021, at 4:00 p.m. revealed that at approximately 10am resident was wandering the hallway exit seeking. This nurse redirected resident back to his room. At approximately 12 pm resident left his room and was attempted to get on the elevator. This nurse coaxed [Resident] out of the elevator. There was a staff member already on the elevator door to [Resident] getting on. Wander (a tracking device designed to prevent a person at risk from leaving a facility unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person) placed on the left ankle at this time. At approximately 1:00pm I was rounding on my residents and [Resident] was in his room eating lunch. At 1:20 pm front desk personnel came to 3rd floor to inform me that [Resident] was found outside . by the security after a fall. This nurse and the e-team nurse met .911 (Emergency Medical Services) was called due to the laceration on resident (right side) forehead. Continue review of the clinical record for Resident R318 revealed the resident was transferred to the hospital for evaluation and returned to the facility in the evening of January 17, 2021 and subsequently required stitches to laceration sustained on right side of forehead from fall during elopement. Review of Resident 318's physician documentation dated January 18, 2021 confirmed that the resident left the facility and fell in the parking lot. The resident hit his head and sustained a laceration to the right eyebrow area with sutures in place. Interview conducted with licensed nurse, Employee E5 on August 13, 2021 at 8:45 a.m. revealed that at the beginning of the shift the morning of January 17, 2021, Employee E5 received report that Resident R318 needed to be monitored as a fall risk as the resident kept attempting to get up and walk around. Interview with Employee E5 confirmed that Resident R318 needed assistance with transfers and walking due to weakness and unsteady balance. Continued interview with Employee E5 confirmed that Resident R318 was at risk for elopement and was showing exit seeking behaviors the morning of January 17, 2021. Employee E5 reported needing to redirect Resident R318 on multiple occasions. Employee E5 revealed that due to Resident R318's exit-seeking behavior, and attempting to get on elevator, Employee E5 placed a wander guard to the resident's ankle. During interview with Employee E5 it was reported the last time Employee E5 had seen Resident R318 was having lunch in his room, during rounds, at approximately 1:00 p.m. It was confirmed during the interview that Employee E5 did not realize Resident R318 had eloped and fallen, until a phone call was received from front desk personnel at approximately 1:20 p.m. Further review of facility documentation related to Resident R318's elopment revealed that the wander guard device placed on Resident 318's left ankle was non-functioning with the alarm system, and needed to be replaced. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services