Every finding on record at Saint Joseph Villa

Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required.Findings include:On January 30, 2026, at 10:07 a.m., an observational tour was conducted with the Social Worker, Employee E9, on the second floor nursing unit. The tour of the facility revealed that staffing information was not posted in the lobby or on the nursing units.In an interview on January 30, 2026, at 10:15 a.m., the Administrator confirmed that accurate nurse staffing information had not been posted in the lobby or on the nursing units.28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understood and that a notice was sent to the Office of the State Long- Term Care Ombudsman for two of three closed records reviewed (Resident R104 and R106). Findings include: Review of Resident R104's medical records revealed that on November 21, 2025, the resident was transferred to the hospital on November 21, 2025, for seizures. Continued review failed to reveal documentation of a written notification to the residents or resident's representative and the State Long- Term Care Ombudsman, notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator on January 30, 2026, at 1:00 p.m. confirmed this finding. Review of Resident R106's clinical records revealed that the resident had a BIMS score of three, indicating cognitive impairment. Continued review revealed that the resident was discharged from the facility on November 6, 2025. Further review failed to reveal documentation of a written notification to the residents or resident's representative and the State Long- Term Care Ombudsman, notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator on January 30, 2026, at 1:00 p.m. confirmed this finding. Interview conducted on January 30, 2026, at 1:30 p.m. with The Social Worker, Employee E9, Executive Director, Employee E11, and the assistant Director of Nursing, Employee E3, confirmed the above-mentioned findings and stated that it is not facility practice providing the residents and/or their representative with a written notice for transfers or discharges. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for two of two agency personnel files reviewed (Employees E5, E6).Findings include:Review of facility staffing schedules revealed that Employee E5, registered nurse; worked at the facility on June 16, 2025, as agency nursing staff.Review of facility staffing schedules revealed that Employee E6, license nurse, worked at the facility on April 9, 2025, as agency nursing staff.Review of personnel files for Employee E5, agency registered nurse revealed that there were no skills evaluations or training available for review at the time of the survey.Review of personnel files for Employee E6, an agency-licensed nurse, revealed no skill evaluation validated by facility staff at the time of the survey.Interview on January 29, 2026, at 10:13 a.m. the Director of Nursing confirmed that the facility did not conduct in-service training or skills competency evaluations for Employee E5, agency registered nurse; Employee E6, agency licensed nurse.Interview on January 29, 2026, at 11:46 a.m., Employee E8, Human Resources Director, confirmed that the Director of Nursing conducts skill competency evaluations for agency staff and that the Human Resources Department does not conduct competency evaluations for agency staff.28 Pa. Code 201.20(a)(b) Staff development28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of clinical record, review of facility policy, it was determined that the facility failed to ensure to maintain an effective infection control program for two of twenty-three residents observed (Residents R87 and R88). Review facility policy on Catheter Care, Urinary revealed that under section Purpose The purpose of this procedure is to prevent urinary catheter associated complications including urinary tract infection. Under section Infection Control #2. Be sure the catheter tubing and drainage bag are kept off the floor.Review of resident R87's Clinical Record revealed that resident R87 was admitted to the facility on [DATE], with the diagnosis of but not limited to Neuromuscular Dysfunction of the Bladder.Further review of Resident R87's Clinical Record revealed a physician's order for Indwelling foley catheter 24 Fr. 30ml balloon to gravity drainage for neurogenic bladder every shift for Neurogenic Bladder. further, physician's orders revealed an order for Assure catheter drainage system bag is in dignity bag every shift. Ensure that bag is below the level of the bladder to ensure proper drainage every shift dated 2.11.20.Observation of Resident R87 conducted on January 28, 2026, at 11:21 AM reveal that resident was on bed asleep.Further observation revealed that resident had a urine bag under the bed lying on the floor.Interview with licensed nurse Employee E3 and licensed nurse Employee E4 confirmed that Resident R87's catheter was lying on the floor.Review of Resident R88's clinical record revealed that Resident R88 was admitted to the facility on [DATE], with diagnosis of but not limited to Asthma.Review if resident R88's progress note dated January 28, 2026, revealed that Resident R88 returned from an appointment with a mask. When asked what happened she stated she had been coughing. T97.8, R18, P68, B/P 128/72. Resident R88 had some wheezing at lung bases, reported some discomfort with a deep inhalation. MD made aware and ordered chest x -ray. Rapid swab for COVID, RSV (Respiratory Syncytial Virus), and Influenza negative. PCR (Polymerase Chain Reaction a laboratory technique used for diagnosing infectious diseases like COVID 19 and influenza) obtained. Droplet Precautions initiated).Interview with Resident R88 conducted on January 28, 2026, at 1:05PM revealed that she was coughing so she started wearing a mask.Observation conducted on January 29, 2026, at 10:13am revealed that Resident R88's room had a signage for Droplet Respiratory Precaution with instruction for staff to wear gown, gloves, N95 and face shield when entering room. Further observation revealed that housekeeping Employee E10 walked into Resident R88's room wearing glove but not wearing a gown, not wearing N95 or any mask and not wearing a face shield. Interview with infection control nurse confirmed that resident R88 was on droplet precaution and that all staff must wear mask, N95, gown and gloved when entering Resident R88's room. 28 Pa. Code 211.12(d) Nursing services

Based on staff interviews, review of the clinical record and facility documentation, it was determined the facility failed to ensure a resident was properly monitored and assessed during a hot pack treatment. This failure resulted in actual harm to Resident R302 who sustained a burn on the right shoulder (Resident R302). Findings include: Review of the facility's undated policy, Commercial Hot Packs/Thermal Agent Treatment, indicated the rehabilitation therapist will follow established techniques when applying commercial hot packs as a treatment modality. Further review of the policy indicated the packs are stored in a thermostatically controlled cabinet in water at a temperature of 150-170 degrees Fahrenheit. Continued review of the policy indicated that prior to the application of the commercial hot packs, a physician's order will be obtained and the resident will be evaluated for any contraindications or precautions, as well as all risk and benefits are clearly communicated to the resident. Continued review of the above policy stated the following: Check area every 5-10 minutes after moist heat pack has been applied j. Remove pack after treatment, dry gently and inspect area for any unusual signs k. Discard wet linen according to facility protocol and return moist heat pack to hydrocollator (stainless-steel therapeutic liquid heating device. It is used to heat bentonite-filled cloth heating pads, which are placed on patients to achieve rapid heat for specific body muscle groups. The hydrocollator heats the pads up to 175 F. The unit contains a wire rack to prevent contact of the packs with the bottom of the tank) l. Treatment time should be 15-25 minutes. Residents should be checked every 5-10 minutes for signs of skin irritation and burning. Consideration should be taken when using commercial hot packs with individuals who demonstrate: a) Sensory impairment (e.g., diabetes, CVA (cerebral vascular accident), neuropathies (damage to one or more nerves), nerve root impairment) b) Circulatory impairment (e.g., arteriosclerosis (the thickening and hardening of the walls of the arteries), venous insufficiency, phlebitis (inflammation of a vein) c) Cancer d) Very young/very old resident e) Skin rashes Review of the user manual for Hydrocollator M-2m Mobile Heating Unit utilized by the facility revealed under section titled Safety Precaution indicated, Treatment time should not exceed 30 minutes; Always wrap the HotPac with a towel or [NAME] cover before handling or applying to patient; Constantly monitor the HotPac application to ensure that the skin is not becoming too hot. The Safety Precaution' section also indicated that damage to an individual's skin can occur from exposure to extreme heat or cold, and that the individual applying the treatment should note instructions for proper use. Continued review of the Safety Precaution section indicated the HotPac should not be applied over sensitive skin or in the presence of poor circulation and that individuals with circulatory problems should consult with a physician before using this product. During observation conducted on February 25, 2025 at 2:30 p.m. the Hydrocollator was observed in a room in the therapy department. During the above observation accompanied by the Director of Rehabilitation (Employee E5), it was reported the rehabilitation department has not utilized the unit since November 2024. Review of Resident R302's November 2024 physician orders revealed the resident diagnoses of Anemia Hyperlipidemia (high cholesterol); Hypertension (high blood pressure), and Diabetes (disease characterized by high blood sugars). Review of Resident R302's physician documentation dated November 8, 2024 at 12:48 p.m. revealed Resident R302 was admitted into the facility on [DATE], for rehabilitation services after being treated at a local hospital from October 28, 2024 through November 6, 2024 for a right lower extremity hematoma. The resident was also treated for an elevated INR (International Normalized Ratio- a measure that of how long it takes for an individual's blood to clot). Review of Resident R302's nursing note dated November 22, 2024 at 3:03 p.m. revealed the resident was discharged home on the above referenced date. Review of information submitted to the State Survey Agency on November 13, 2024 revealed, on the morning of November 13, 2024, Resident R302 complained that his/hers shoulder was irritated. Continued review of the information submitted to the State Survey Agency indicated the resident notified the licensed nurse, (Employee E6), who found a burn-like area on (his/hers) right shoulder. The resident told the nurse that his/hers shoulder was stiff at therapy the day prior (November 12, 2024) and that he/she requested heat therapy, which was applied to him/her. Review of a written statement from licensed nurse, Employee E6 dated November 13, 2024 revealed the resident reported to the nurse that his/hers should has [sic] something irritating him. Employee E6 reported that he/she unsnapped the resident's gown and that she saw open skin area to his/hers right shoulder. Employee E6 reported in her statement that the resident told her that while he/she was at therapy the towel was to hot. Employee E6 statement indicated that she notified the wound nurse, unit manager and therapy. Made wound nurse UM (unit manager) Therapy aware. Review of Resident R302's nursing note by licensed nurse, Employee E6 dated November 13, 2024 at 12:38 p.m. indicated Nurse came to residents room to give morning medication today. Resident reported to nurse that (his/hers) right shoulder is irritated. Nurse asked to look at the shoulder. Upon unsnapping the hospital gown the nurse noticed open area to right shoulder and small blister side by side of each other. Resident explained yesterday 11/12/24 (he/she) felt a draft in his/her room while sitting in the recliner in (his/hers) room by the window, which made (his/hers) shoulder (right) achy. (He/she) goes on to explain (he/she) had therapy yesterday around 2pm where (he/she) rec'd heat to the right shoulder and that the towel was put on (his/hers) shoulder for the shoulder pain. Nurse ask was the towel hot. Resident said the towel was wet and started to get hot. Nurse said ok. Wound nurse, Unit manager and Therapy made aware. During an interview with licensed nurse, Employee E6 on March 3, 2025 at 12:45 p.m. Employee E6's statement and nursing notes regarding the incident were reviewed and confirmed. Review of a nursing note from the wound nurse, Employee E7 dated November 13, 2024, at 10:48 a.m. indicated that she was notified by nurse of injury to right shoulder. Resident was in therapy yesterday receiving heat therapy to right shoulder, nurse noted this morning a burn-like area. Area presents 2.5cm (centimeters) x 2.0cm, 100% pale pink tissue, no drainage, periwound intact, adjacent intact blister 0.3cm x 0.5cm, no drainage. Appears as scar tissue that experienced sensitivity to heat source and had mild reaction when heat was applied. Cleansed area with NSS (normal saline solution), applied Vaseline and covered with foam dressing. All appropriate parties notified. Orders and care plan updated. During an interview with the wound nurse, Employee E7 on March 3, 2025, at 12:39 p.m. Employee E7's notes, including the treatment provided, description of the injured areas, including the size of the injured areas, was reviewed and confirmed with the wound nurse. Review of an undated written statement from Employee E9 (Physical Therapy Assistant-PTA) indicated the resident requested the hot pack treatment to (his/hers) right shoulder at the end of physical therapy treatment due to pain, and the PTA attended to and observed the resident during the treatment. The PTA wrote in his statement that he asked the resident multiple times if the heat felt ok, and the resident reported that it felt fine and that (resident) was without complaints. The PTA reported the resident had two layers of clothing on (his/hers) shoulder and that the hot packs were covered in wrap plus one folded towel and one extra towel. Physical Therapy Assistant, Employee E8 was terminated on November 13, 2024, the day after the incident occurred, and was not available for an interview. During an interview with the physical therapist (Employee E10) on February 28, 2025 at 1:32 p.m. it was confirmed the incident occurred on November 12, 2024 and the treatment utilizing the hotpack took place in the therapy department. When asked if the treatment the resident received from Employee E9 was an authorized treatment, Employee E10 reported the treatment modality was not authorized in the resident's plan of care with the therapy department, and the PTA did not ask a physical therapist if it was permitted to provide Resident R302 with this treatment modality. Resident's plan of care was reviewed with the physical therapist and it did not include the use of the hotpacks. Continued interview with physical therapist, Employee E10 revealed the PTA did not document the treatment modality with the hotpacks, as required by therapy department. There was no documentation the PTA observed the skin areas that were being treated during the treatment or after the treatment, or how long the treatment actually occurred, due to the absence of clinical documentation. The facility failed to ensure that Resident R302 was properly monitored and assessed by physical therapist staff during the administration of a hot pack treatment which resulted in actual harm to Resident R302 who sustained a burn on the right shoulder. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop and implement interventions per the comprehensive care plan for two of 21 residents reviewed (Resident R306 and R67). Findings Include: Review of facility policy Care Plans, Comprehensive Person-Centered revised March 2022 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of Resident R306's clinical record revealed the resident was admitted to the facility on [DATE], status post a mechanical fall at home on February 12, 2025, resulting in a left hip fracture and subsequent left hip surgery on February 14, 2025. Continued review of Resident R306's clinical record revealed an admission summary dated February 18, 2025, that revealed Resident R306 was weight bearing as tolerated (WBAT) with posterior hip precautions for six weeks. Review of Resident R306's comprehensive care plan dated February 18, 2025, revealed the resident had an activities of daily living self-care performance deficit related to deconditioning, limited mobility, limited range of motion, and status post left hip surgery. Intervention dated February 18, 2025, revealed Resident R306 should be transferred with assistance of two staff. Observations on February 25, 2025, at 1:27 p.m. revealed Resident R306 was assisted with one staff member, Nurse Aide Employee E8, from her recliner chair into a weighing chair scale in her room. Interview on February 25, 2025, at 1:30 p.m. with Nurse Aide, Employee E8, confirmed this employee transferred Resident R306 from the recliner into the weigh chair scale without assistance from another staff member. Observation on February 25, 2025, at 11:30 a.m. revealed resident R67 wearing a brace on his right lower leg and complaining that it was bothering him. He indicated that they had just fixed it, but all they did was glue it. Review of Resident R67's clinical record revealed that she was admitted on [DATE], with diagnoses of abnormalities of gait (pattern of walking) and mobility. Further review revealed a physical therapy note indicating a check on the right foot AFO (ankle foot orthidic, a support to control the position and motion of the ankle) due to complaints of irritation on the back of the resident's right lower leg. A review of the care plan for Resident R67 revealed no plan of care for the AFO. Interview with the Director of Nursing on February 27, 2025, at 2:35 p.m. confirmed that Resident R67 had no care plan for the AFO being used on his right foot. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with resident and staff and clinical record review, it was determined that the facility failed to obtain a physician's order regarding the use of an AFO (ankle foot orthidic, a support to control the position and motion of the ankle) and failed to clarify a physician's order pertaining to a resident's alcohol consuption for two of twenty- one residents reviewed (Resident R67 and R4). Findings include: Observation on February 25, 2025, at 11:30 a.m. revealed Resident R67 wearing a brace on his right lower leg and complaining that it was bothering him. He indicated that they had just fixed it, but all they did was glue it. He then pulled out an old brace that he said fit much better. Review of Resident R67's clinical record revealed that she was admitted on [DATE], with diagnoses of abnormalities of gait (pattern of walking) and mobility. Further review revealed a physical therapy note indicating a check on the right foot AFO due to complaints of irritation on the back of the resident's right lower leg. A review of physician orders for Resident R67 revealed no physician order for the AFO. Interview with the Director of Nursing on February 27, 2025, at 2:35 p.m. confirmed that Resident R67 had no physician order for the AFO being used on his right foot. Review of the facility's undated policy, Alcoholic Beverages, indicated that a physician's order obtained that residents may have alcoholic beverages, and that the Nurse Supervisor receiving the order must contact the pharmacist to determine if any of the resident's current medications would interact with alcohol. Continued review of the policy indicated that should there be a medication that would interact with the alcohol, the Nurse Supervisor must inform the physician of such medication. Review of the February 2025 physician orders for Resident R4 included diagnoses of hypertension (high blood pressure); history of falling; depression (major loss of intrest in pleasurable activities); multiple sclerosis (slow progressive diease of the central nervous system); heart failure. Review of February 2025 physician orders included a physician's order dated September 19, 2019, and every month thereafter stating that Resident R4 could have alcoholic beverages. ALCOHOLIC BEVERAGE - May have wine. Continued review of the physician's order did not indicate if there was a specific amount of wine the resident could have and how often she could have it. Continued review of the resident's Medical Administration Record (MAR-documentation by nursing staff when a medication has been administered), and Treatment Administration Record (TAR-documentation by nursing staff when a treatment has been administered to a resident) did not include a section on either of the administration records that where nursing staff would document that the resident had wine any time it was given to her by nursing staff. During an interview with Resident R302 on February 28, 2025 at 12:40 p.m. the resident reported that she is served wine at least once a week on Fridays. During an interview with Employee E11 (unit manager) on February 28, 2025 at 12:36 p.m., Employee E11 confirmed that the physician's order did not clarify that amount of wine that Resident R4 could have, and that she would check with the physician. 28 Pa. Code:201.18(b)(1)(3) Management 28 Pa. Code:211.12(d)(1)(5) Nursing services

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 on February 25, 2025, at 9:30 a.m. with Employee E3, Dining Operations Manager (DOM), revealed the following concerns: Observations in the receiving area revealed the trash compactor with the metal door ajar and the bags of trash inside exposed. Further observations revealed the cardboard recycling dumpster with two of the sliding doors open and the can recycling dumpster with both top doors open and the side sliding door open. Observation near the receiving door revealed four wooden pallets laying on the ground with broken pieces of splintered wood scattered around on the ground, three large grey trash cans laying on the ground, two large blue laundry bins half filled with rain water and trash including a broken hot holding pan warmer. Interview with the DOM on February 25, 2025, at 9:30 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 observation, review of facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food related to labeling and staorage of foods in the main kitchen. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policies entitled Food and Supply Storage last reviewed by the facility on January, 2021, indicated 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. Under Procedures it further states,Cover, label and date unused portions and open packages. Complete all section on the . orange label or use the .Fresh date or other approved labeling system. Observations conducted during the initial tour of the kitchen with the facility's Dietary Manager, Employee E6 on April 23 , 2024, at 9:36 a.m., revealed the following: Walk in freezer had items such as frozen pies, chocolate cakes, chicken nuggets that were opened but not labeled. Walking in dairy refrigerator #1 had opened cheeses and slicing meats that were only dated with one date, and it was unclear if that was opened date or expiration date. Walk in refrigerator #2 had left over pasta that was not labeled. Dry Storage room had items such as dry peas, rice bags, spices whole poppy seeds, ground oregano, rosemary leaves, hollandaise mix, dry crispy onion, creamy rice and large containers of sugar, rice, flour, and thickener were all open and were not labeled with any dates. On April 26, 2024, at 9:41 a.m. more observations were made in the kitchen with Dining Manager, Employee E10 revealed refrigerator #2 had produce pasta left uncovered and unlabeled. Raw salmon packaged in the clear bag was stored on the middle shelf and there was veggie produce beneath. A cart full of ready to serve food which had a sheet of shrimp that was not covered or dated. Dry Storage room continued to have items peppermint pieces, pasta, sea food breading mix, granola, chips, thickener, sugar, flour, rice in large bins that were not labeled with any dates. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on review of facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked bed wheel brake for one of 20 residents reviewed. (Resident R83) Findings include: A review of clinical record for Resident R83 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, abnormal posture, and unspecified mental disorder due to known physiological condition. Review of Resident R83's quarterly Minimum Data Set (MDS- assessment of resident's care needs) date on April 9, 2024, revealed that the resident was assessed a requiring one-person physical assist for bed mobility. Review of Resident R83's care plan on May 5, 2023, revealed that Resident R83 was able to turn and reposition in bed with the assistance one person assist for bed mobility. Review of incident note dated on April 16, 2024, confirmed, and revealed that Resident R83 rolled off side of bed during care and hit head has a laceration to L (left)-forehead. Resident R83 has aphasia-unable to say what happened. Review of facility investigation dated, April 16, 2024, revealed that during incontinence care Resident 83 slid down between the bed and the wall to the floor while nurse aide, Employee E7 was turning resident to the right side to wash her back. Resident was transfer to the hospital. Review nurse aide, Employee E7, statement on April 16, 2024, stated that resident rolled out of bed due to bed moving as I was giving care. I immediately got the nurse and aide. Review of nursing documentation notes on April 16, 2024 3:26 p.m. revealed that Assessed forehead laceration, band-aid removed. 2.7cmx 2.5cm, 100% approximated with steri-strips, dried blood to medial aspect and upper right edge. No drainage, surrounding skin intact. Left open to air. Returned from ER at 12:15 p.m. assisted into bed. Forehead laceration with steri strips and band aid. Abrasion Left shoulder s/p fall. NO CT evidence for acute intracranial hemorrhage or mass effect Interview on April 24, 2024, at 1:41 p.m. with the Director of Nursing, Employee E2, revealed Resident R83 slid down between the wall and bed after nursing assistant turning resident to the right side to wash her back. The reason why resident slid down was because the bed wheels brakes were unlocked. Interview on April 25, 2024, at 10:49 a.m. with nursing assistant, Employee E7, revealed that assumed top brakes were lock but they were unlock. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on resident council interview, staff interviews, review of facility policy and reviews of the established meal time schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast in two of two nursing units. (3rd floor and 2nd floor unit). Findings include: A review of facility policy titled Snacks (between meal and bedtime), serving last revised September 2010 revealed The purpose of this procedure is to provide the resident with adequate nutrition it further states under Steps in the Procedure Place the snack on the overbed table or serving area. A review of the established meal schedule for the residents revealed that the supper meal was scheduled for 4:30 p.m., and that the breakfast meal the following morning was offered at 7:15 a.m This was a 15 hour meal span of time until breakfast the following day. An interview was conducted on July 14, 2023, at 10:30 a.m. during the resident council with alert and oriented Residents R6, R16, R34, R44, R82, R84, revealed that snacks were not offered at bedtime. Residents reported that they do eat dinner at 4:30 p.m. and get hungry at night time. An interview with Dietician, Employee E5 held on July 14, 2023, at 1:07 p.m. revealed that she learned from residents that they were not being given night snacks and was talking to unit managers to address it. An interview with license nurse, unit manager Employee E4 on July 17, 2023, at 9:41 a.m. revealed night snacks come up around 7:00 p.m. and distributed between 7-8 p.m. It a responsibility of the nursing aids to distribute snacks to residents and nursing staff responsible to distributed to resident who have a specific order for a snack. Employee E4 has seen a audit tool being developed to strengthen the night snack delivery to residents. Surveyor requested to see when the last night snack audit was performed and there was no documentation provided. An interview with nursing aide, Employee E25 on July 17, 2023, at 9:41 a.m. revelaed that night snacks were being left on the countertop in the dining room, some residents came up and got them. Employee E25 indicated that personally taking snacks to assigned residents, but not every staff did it. An interview with nursing aide, Employee E24 on July 17, 2023, at 9:56 a.m. reported that night snacks were crackers, juice, water, and goldfish crackers. 28 Pa. Code: 201.14(a) Responsibility of license

Based on clinical records review and staff interview, it was determined that the facility failed to ensure complete documentation related to blood sugar levels for one of 24 records reviewed. (Resident R33) Findings include: Review of Resident R33's Minimum Data Set (MDS- assessment of resident care needs) significant change assessment dated [DATE] indicated that the resident had an active diagnosis of diabetes mellitus (a disorder of carbohydrate metabolism, whereby, the body has an impaired ability to produce or respond to insulin and maintain proper blood glucose in the blood). Continued review of the MDS assessment revealed that this resident was using insulin injections regularly. Review of Resident R33's July 2023 physician's order indicated an order for Novolog (insulin) 5 units to be administered to Resident R33 at breakfast for a blood glucose reading of greater that 351. The physician's order for Resident R33 indicated that Novolog (insulin) 7 units was to be administered at mid-day and evening. Review of Resident R33's July 2023 Medication Administration Record revealed that on July 2, 2023 the blood glucose reading was 467, July 5, 2023 the blood glucose reading was 451 and July 8, 2023, blood glucose was 459. Clinical record review revealed that the physician had ordered the nursing staff to recheck to blood glucose after two hours; if the level obtained was greater than 400; which was indicative of hyperglycemia. Clinical record review for Resident R33 revealed that the nursing staff failed to document the rechecking of the blood glucose after two hours on July 2, 5 and 8, 2023. Interview with the Director of Nursing, Employee E2, and Licensed nurse, Employee E3 on July 13, 2023 at 2:00 p.m. confirmed that there was no documentation that the resident's blood sugar was recheck after 2 hours. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211,12(d)(1) Nursing services

Based on review of facility policy, clinical record review, observation, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to hand hygiene and wound care for one of 24 residents reviewed (Resident R39). Findings include: Review of facility policy titled Wound Care Policy and Procedure, dated May 2023, revealed that wound care is to be done following aseptic technique. Review of the Pennsylvania Department of Health document titled Wound Care Observation Checklist for Infection Control, dated April 2018, revelaed that gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities. Review of clinical documentation for Resident R39 revealed that she had an unstageable, facility acquired pressure ulcer on her right calf (an injury formed by pressure on the skin, classified into stages based on the depth of the wound and the layers of skin, fat and muscle involved; wounds are unstageable when they contain too much dead tissue to visualize the base of the wound) first identified on April 10, 2023. Other wounds present from admission included a stage 4 pressure ulcer (a wound that is completely through the skin and involving the underlying fat and muscle tissue) on her sacrum, unstageable pressure wounds to both of her heels, a deep tissue injury (a pressure related wound with intact skin) of the side of her left great toe, and a non-pressure related wound of her right second toe. Continued review revealed that Resident R39 was admitted on [DATE], and had diagnoses including, but not limited to, stage 4 pressure ulcer of sacral region, unspecified protein-calorie malnutrition, peripheral vascular disease, unspecified, and muscle weakness. Observation of wound care for Resident R39 was conducted on July 14, 2023, at 9:55 a.m. with Employee E14, the wound care Registered Nurse for the facility. Employee E14 prepared a clean field and assembled the wound care supplies for Resident R39. Supplies assembled included two open packages containing partial sheets of DermaGinate/Ag dressing (a highly absorbent dressing which is used for wounds with secretions, which is also infused with silver as an antimicrobial agent), normal saline solution, rolled gauze, skin prep pads (premedicated towelettes which are applied to create a barrier against moisture, adhesive or friction), two foam dressings with adhesive borders which had been labeled with the current date, several 2x2s (two cm long by two cm wide gauze pads), several 4x4s (four cm long by four cm wide gauze pads), cotton tipped applicators, and Santyl ointment (an ointment which is used to help breakdown dead tissue in a wound to allow the wound to heal). Interview with Employee E14 at this time of the observation revealed that the DermaGinate/Ag dressings had been opened and partially used during previous wound care, and that the remaining product had been saved for future use. She also stated that sacral wound treatment was performed by the prior shift. Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from Resident R39's right calf, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She used a cotton applicator to apply Santyl to the wound bed, applied a 2x2 soaked with saline, applied skin prep to the area around the wound, and covered it with a foam dressing. Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from R39's right second toe, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She used a cotton applicator to apply Santyl to the wound bed, applied a dry 2x2, and tape which had previously been labeled with the current date. E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from R39's right heel, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound. At this time, she did not perform hand hygiene and put on clean gloves. She then applied DermaGinate/Ag to the wound, covered it with and ABD and wrapped it with rolled gauze and secured it with tape labeled with the current date. Employee E14 performed hand hygiene and put on clean gloves. She removed the soiled dressing from the base of R39's left great toe, then she performed hand hygiene and put on clean gloves. She applied skin prep to the area and covered it with a foam dressing. At this time, she did not perform hand hygiene and put on clean gloves. Employee E14 removed the soiled dressing from R39's left heel, then she performed hand hygiene and put on clean gloves. She used a 4x4 soaked with saline to cleanse the wound, then performed hand hygiene and put on clean gloves. She then applied DermaGinate/Ag to the wound, covered it with an ABD and wrapped it with rolled gauze and secured it with tape labeled with the current date. Employee E14 gathered the trash and placed it in the waste basket, removed her gloves and placed them in the waste basket as well. She then removed the bag from the room and placed it in an appropriate receptacle and performed hand hygiene. As noted above, Employee E14 did not perform hand hygiene at four separate opportunities during wound care for Resident R39. The DermaGinate/Ag that was used was residual product from a package that had been previously opened and exposed to air. Alginate dressings should not be saved after opening as they absorb moisture from the air which can compromise their integrity. Also, once a sealed, single use package has been opened, any remaining product should be disposed of as exposure to the air and other surfaces can potentially introduce infectious agents to the product. Following wound care observations, interview with Licensed staff, Employee E14 on July 14, 2023 at 10:15 a.m. confirmed that she did not perform hand hygiene at the opportunities noted above. Interview with the Director of Nursing on July 14, 2023, 10:45 a.m. confirmed that the missed opportunities for hand hygiene by E14, as well as the use of dressings from a previously opened package constituted a breach in infection control practices. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, review of residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with facility policy, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency was identified as Immediate Jeopardy past non-compliance. Findings Include: Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR - Cardiopulmonary Resuscitation is defined as an emergency lifesaving procedure performed when the heart stops beating. Also, CPR incudes the manual application of chest compressions and ventilations to patients in [CONDITION(S)], done in an effort to maintain viability until advanced help arrives), revised [DATE], revealed If a resident is found unresponsive and not breathing, a staff member who is certified in CPR/BLS shall initiate CPR/BLS unless it is known that a Do Not Resuscitate (DNR) order exists for the resident. CPR/BLS shall be continued until an emergency medical team arrives or the resident responds. The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services (EMT), in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. Review of Resident R141's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) and [CONDITION(S)]. Review of Resident R141's Do Not Resuscitate Request/Order form (Form that guides facility staff regarding the resident's end-of-life care and can give facility staff permission not to perform CPR) dated [DATE], revealed that the resident representative elected to have CPR and wanted to be hospitalized . This form was signed and dated by the resident representative and physician. Review of Resident R141's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R141 dated [DATE] revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 8 which indicated that the resident's cognitive status for daily decision making was moderately impaired. Review of Resident R141's interdisciplinary progress notes revealed documentation by the Registered Nurse Supervisor, Employee E17, on [DATE], revealed, that the employee was called to assess the resident and found the resident in bed, not responding but breathing and with a pulse. Oxygen saturation obtained by the nursing assistant on monitor. Employee E17 immediately called 911 and power of attorney. Shortly thereafter she was called back to the room because the resident had a large bowel movement and color change according to the nursing assistant. Employee E17 was unable to palpate pulse and observed no respirations so Employee E17 immediately initiated CPR while nurse went to get the crash cart. Continued review of the progress note revealed that the resident passed away and had no palpable or audible pulse and no respiration for 1 minute. Further review of the progress note revealed no evidence that the Employee E17 or other facility staff continued CPR until 911/emergency medical personnel arrived or a reason for stopping CPR before emergency medical personnel arrived. Review of facility documentation dated [DATE], revealed that Resident R141 was talkative and alert and became unresponsive while using the sit to stand lift. The Resident did not respond to their name or physical stimuli and arms went limp. Supervisor assessed Resident R141, and oxygen saturation was 70. Oxygen was raised to 6L/min. oxygen saturation did not rise. Call was placed to 911 and physician and family. Further review of the documentation revealed that resident evacuated large amount of stool, no respirations or pulse. Supervisor initiated CPR at 9:47 a.m., Resident was without pulse or respiration for eight minutes. Supervisor pronounced death at 9:55 a.m. emergency medical personnel arrived at the facility at 10:07 a.m. Continued review of the document revealed that all residents requiring CPR will have chest compression and rescue breath until EMT/emergency help arrives. Interview with Employee E2, Director of Nursing, on [DATE], at 12:07 p.m. stated Employee E17 started CPR on Resident R141 when she was found without a pulse or respiration. Employee E17 continued CPR for 7 minutes and stopped CPR. Resident R141 was noted without a pulse or respiration for 1 minute. Employee E2 stated Employee E17 stopped CPR prior to the arrival of 911/emergency medical personal. Employee E2 further stated that the staff is expected to continue CPR until 911 arrives once CPR is initiated. If an employee is unable to continue CPR another staff should take over CPR. Continued interview with Employee E2 stated facility did not have an AED machine (AEDs are used to revive someone from sudden [CONDITION(S)].) and Resident R141 did not receive AED application from staff or emergency services. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 12:30 p.m. confirmed that Resident R141 did not receive appropriate cardiopulmonary resuscitation until EMT arrived according to the facility policy, resident representative's wishes, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's failure to continue CPR on a resident who elected to receive CPR and ordered by the physician to receive CPR until Emergency Medical Services arrived caused harm to the resident who subsequently died . This failure also puts other residents who were full code/elected to receive CPR at risk for harm. Review of facility documentation revealed that, as of [DATE], 94 residents lived in the facility of which 20 residents elected to receive CPR This deficiency was identified as Immediate Jeopardy past non-compliance. The NHA and DON were notified of the Immediate Jeopardy on [DATE], at 3:25 PM. An Immediate Plan of Correction was requested. The Immediate Plan of Correction was provided by the facility, on [DATE], at 11:15 a.m. was accepted. On [DATE], the facility initiated a plan of correction to address the failure to continue CPR on a resident who elected to receive CPR and ordered by the physician to receive CPR until Emergency Medical Services arrived. The Facility's plan of correction included the following: 1. CPR was initiated on [DATE], at 9:47 and stopped at 9:55 with no pulse no respirations. EMT arrived 10:07. Staff member Employee E17 educated to continue to provide CPR until EMT arrives. Completed [DATE]. 2. Educate staff to ensure CPR is continued till EMT arrives. Started [DATE]. All nurse managers [DATE]. All nursing staff [DATE]. 24 out of 27 of the licensed staff were educated by [DATE] 3. All deaths were reviewed to ensure CPR was continued till EMT's arrived with 100% compliance. All nurse CPR certifications were up to date as of [DATE]. 4. Code Blue work sheets will be used during all codes and submitted to QAPI for review. 5. Mock code drills were run on all shifts [DATE] - [DATE]. CPR training will be provided by the facility. Continue to review at Nurses meetings and Orientation. 6. Audit and submit all Code worksheet to QAPI for review and continued compliance. Audit completed from [DATE] till present and there were no full codes. The facility alleged compliance with their plan of correction as of [DATE]. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on [DATE]. Audits were initiated to ensure that CPR was continued till EMT's arrived with 100% compliance. Facility developed a Code Blue work sheets and it was used during all codes/mock code drills. An audit tool was developed and completed by nursing director. The facility reviewed and updated their policy related to CPR. Additionally, the facility Re-educated Employee E17 for not following facility policy. Facility educated all staff related to facility policy, Cardiopulmonary Resuscitation, and Rapid Response Drill and Facility Practice. Interviews were conducted with licensed nursing staff and Registered Nurses regarding trainings and competencies related to providing cardiopulmonary resuscitation until EMT arrived according to the facility policy, resident representative's wishes, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses verbally demonstrated knowledge of cardiopulmonary resuscitation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(2)(3)(e)(1) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on the review of clinical records, facility policies, facility documentation and interviews with staff it was determined that the facility failed to provide appropriate supervision and assistance to one resident who required assistance during meals. This failure resulted in actual harm to Resident R26 who spilled oatmeal on her thigh on two separate incidents and sustained [CONDITION(S)]. Finding Include: Review of facility policy, Assistance with Meals revised on August 2022 revealed, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. The staff shall read resident Kardex prior to providing care to the residents. Residents who required feeding assistance will have trays brought to them. This will include residents who prefer to eat in their room or eat in the dining room. The staff will not leave the trays unattended for residents who requires feeding assistance. The staff will begin feeding at the time that they deliver the food. The nursing staff will remove the tray from the resident's room when they are finished. Review of Resident R26's occupational therapy discharge summary dated December 23, 2021 revealed that the resident required moderate staff assistance during meals. Review of the care plan for Resident R26 dated July 18, 2019, revealed the resident required one staff assist for eating and drinking. She required physical assistance with feeding and sometimes for staff to hold the beverages. Further review of the care plan for Resident R26 dated May 17, 2022, revealed that the resident required feeding, once the food is brought into the room, start feeding resident, do not leave food unattended in room. Review of nutrition/dietary note dated March 15, 2022, revealed Resident R26 required staff assistance during meals. Review of nutrition/dietary note dated June 15, 2022, revealed Resident R26 was Total dependency for meals and required 1:1 feeding. Review of MDS (Minimum Data Set-Assessment of Resident care needs) for Resident R26 dated March 17, 2022, revealed that the resident required extensive assistance for feeding and with one person staff assistance. Resident also did not have a BIMS (Brief Interview for Mental Status) assessment due to poor cognition. Review of facility documentation dated May 17, 2022, revealed that Resident R26 was being served breakfast oatmeal by nursing assistant, Employee E18. Employee E18 left the room and returned with her beverages. Employee E18 noticed oatmeal on resident's left thigh and removed it. Nurse called to the room and resident was observed with intact red tissue to left upper thigh. Ice applied and treatment initiated with [MEDICATION(S)] (This medication is used with other treatments to help prevent and treat wound infections in patients with serious [CONDITION(S)]). Review of progress note for Resident R26 dated May 17, 2022, revealed that the nurse was called to resident's room by the nursing assistant who stated that the resident had a burn on her leg. Area measured 7.5 cm x 4.0 cm reddened area to left upper thigh, no blistering or open areas. Review of skin/wound note for Resident R26 dated May 18, 2022, revealed that the area was 60% red tissue and 40% fluid filled intact blister. Blister measured 1.8x2.5x0.1 cm. and the treatment were changed per physician order. Review of skin/wound note for Resident R26 dated May 18, 2022, revealed that the blister was opened with serous drainage. Review of skin/wound note for Resident R26 dated May 18, 2022, revealed that the area was 100% pink tissue with scant amount of serous drainage. Interview with Director of Nursing, Employee E2, on August 25, 2022, at 12:30 p.m. confirmed that Resident R26 required staff assistance during meals and on May 17, 2022, staff left the room after delivering tray without removing resident's tray from bed side table. Employee E2 confirmed that the facility counseled Employee E18 for not following resident's plan of care and facility policy. Further review of facility documentation dated August 11, 2022 revealed that Resident R26 was feeding breakfast herself and the oatmeal bowl overturned and the oatmeal spilled onto Resident R26. Resident sustained reddened area measured 7.0x10.6x0 cm to the left lower quadrant of the abdomen and 10x4.0x0 cm reddened area to left thigh. The possible cause of the incident was documented as Resident was feeding herself oatmeal. The bowl overturned and spilled on the resident. Interview with Director of Nursing, Employee E2, on August 25, 2022, at 12:30 p.m. stated Employee E19, nursing assistant, was assigned for Resident R26 on August 11, 2022. Employee E19 was not familiar with Resident R26. Prior to the providing care/assistance, Employee E19 , did not read Resident R26's Kardex which contained the plan of care and resident specific instructions. Employee E2 confirmed that the Employee E19 did not follow Resident R26's plan of care, Resident R26 spilled oatmeal which resulted burn. Interview with Administrator, Employee E1 and Employee E2, on August 25, 2022, at 12:45 p.m. confirmed that staff did not follow Resident R26's plan of care on May 17, 2022, and August 11, 2022, which resulted in Resident R26 spilling oatmeal and sustaining [CONDITION(S)]. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that a comprehensive person-centered care plan with measurable objectives and goals was developed and implemented for one of 22 residents reviewed related to the use of respiratory requirement (Resident R13). Findings include: A review of facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident, and incorporates identified problem areas. Review of the clinical record for Resident R13 revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) A review of Resident R13's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated June 7, 2022, revealed that resident was cognitively intact, being alert and oriented. An interview with Resident R13 on August 24, 2022, at approximately 11:15 a.m., revealed that he had been using the [CONDITION(S)] Machine (is a form of non-invasive ventilation (NIV) therapy used to facilitate breathing) at nights to help him sleep. A review of Resident R13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed specific instructions for daily and weekly cleaning and storage for the [CONDITION(S)] machine, tubing, water chamber and mask. Interview with the wing nurse on Unit 3B, Employee E13, on August 26, 2022, at approximately 1:05 p.m., confirmed that no care plan was developed for Resident R13 related to the resident's use of a [CONDITION(S)] machine. 28 Pa. Code 211.11(a)(b)(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan

Based on clinical record review, and interviews with staff it was determined that the facility failed to obtain a physician's order regarding hospice care for one of 22 residents reviewed (Resident R84). Findings include: Review of Resident R84's clinical record revealed that she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R84's hospice binder at the nursing office revealed that the resident was admitted to hospice services on November 23, 2021, related to heart failure and shortness of breath. Interview with Employee E5, Unit Coordinator for Unit 3D/E, on August 26, 2022, who confirmed that there is no physician order in the system for Resident R84 to go on hospice in November 23, 2021, and that she checked the hard chart and there was also no verbal order for hospice services. A review of Resident R84's physician orders revealed no orders for hospice services. Interview with the Administrator and Director of Nursing on August 29, 2022, at approximately 2:00 p.m. confirmed that Resident R84 had no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on Centers for Medicare & Medicaid Services (CMS) guidance, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 in the month of August 2022, for 18 of 119 employees with not up to date vaccination status (Employees E32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 44, 45, 46, 47, 48, 49, 50, 51). Findings include: Review of Centers for Medicare and Medicaid Services (CMS) document QSO-20-38-NH Revised 3/10/22, indicated routine staff testing frequency for staff who are not up to date on their vaccinations should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing. This memorandum indicated that facilities in counties with a moderate transimission rate should test their staff who are not up-to-date (a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible) twice per week. Review of the Centers for Disease Control (CDC) guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, indicated in nursing homes, health care personnel who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: in counties with substantial to high community transmission, these healthcare personnel should have a [CONDITION(S)] test twice a week. Review of the county community transmission rate revealed that the county community transmission rate of medium from 8/8/22, through 8/15/22. Review of the facility provided staff testing records for the Week of August 8, 2022, and Week of August 15, 2022, indicated the following for employees with not up to date vaccination status: -Employee E32 had no testing on week of August 8 and week of August 15 -Employee E33 had no testing on week of August 8 and week of August 15 -Employee E34 had no testing on week of August 8 and week of August 15. -Employee E35 had no testing on week of August 8 and week of August 15 -Employee E36 had no testing on week of August 8 and week of August 15. -Employee E37 had no testing on week of August 8 and week of August 15. -Employee E38 had no testing on week of August 8 and week of August 15 -Employee E39 had no testing on week of August 8 and week of August 15- -Employee E40 had no testing on week of August 8 and week of August 15. -Employee E42 had no testing on week of August 8 and week of August 15 -Employee E44 had no testing on week of August 8 and week of August 15 -Employee E45 had no testing on week of August 15 -Employee E46 had no testing on week of August 15 -Employee E47 had no testing on week of August 15 -Employee E48 had no testing on week of August 8. -Employee E49 had no testing on week of August 8. -Employee E50 had no testing on week of August 8. -Employee E51 had no testing on week of August 8. During an interview on 8/26/22, at 1:50 p.m. the Infection Preventionist, Employee, E3, confirmed that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 for employees with not up to date vaccination status. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(5) Nursing services

Based on a Resident Council interviews, observations of both nursing floors and interviews with staff, it was determined that the facility failed to display proper contact information for the State Survey Agency, including the Hotline number on both nursing floors. Findings include: During a Resident Council interview on August 25, 2022, at approximately 10:00 a.m. with five alert and oriented residents who regularly attend resident council meetings. When asked if they know how to contact the Pennsylvania Department of Health, Resident R63 stated she did not know where the Department of Health Hotline number was located, and that she never felt she needed it. Resident R29 indicated that she did not know where to find the number. Observations of both nursing floors after the Resident Council meeting on August 25, 2022, at approximately 10:30 a.m. revealed that the State Department of Health contact information was not posted as required. Interview with Employee E5, Nursing Home Administrator, and Employee E9, Quality Assurance Coordinator, on August 29, 2022, at approximately 11:00 a.m. confirmed that the contact information was not posted as required. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) (e)(1) Management 28 Pa. Code 201.29(i) Resident rights

Based on observation, review of clinical records, facility policy and procedures, facility documentation and interviews with staff, it was determined that the facility failed to ensure that nursing staff had demonstrated the appropriate level of competency in caring for residents identifed as at risk of elopement (act of leaving the facility without notifying staff and/or permission). Findings include: Review of the facility policy titled Elopement Prevention, dated (MONTH) 2011 revealed that all residents who are at risk for harm due to elopement will have preventative measures in place to prevent elopement. Review of the manufacturer guidelines for the facility's wander guard system (device designed to trigger an alarm if the person wearing the device moves into a defined area) revealed that wander guard devices attached to residents can be checked for function either by testing the wander guard tag with a handheld tag reader or by using a wander guard alarmed door to ensure that the tag is detected. The manufacturer's guidelines further stated to record the test including at a minimum, the test date, serial number or resident name and the result of the test. Observation on (MONTH) 6, 2019, at 10:32 a.m. revealed a resident entering the unsecured stairwell on the second-floor nursing unit. Further observation revealed the door to be unlocked and the door opened onto a narrow concrete landing. A sign posted in the stairwell instructed staff to ensure the door was securely closed behind them to prevent residents from accessing the stairwell. Interview with the DOM (Director of Maintenance) on (MONTH) 6, 2019, at 3:32 p.m. revealed that the nursing units had a device to check wander guard placement without having to push residents past the wander guard protected doors but the employee could not locate the device. He was also unaware of a user manual for the wander guard system. Interview with Employee E3, RN, nurse manager, on (MONTH) 6, 2019, at 3:37 p.m. revealed the licensed nurses check the function and placement of wander guard devices on residents on every shift and checks the function of the autolocking doors on every shift by listening for the sound of the alarm. Employee E3 stated that if no residents are on wander guards then only the DOM checks the function of the autolocking doors monthly. Employee E3 stated that it is the responsibility of the charge nurses on each shift to push the resident past a wander guard protected autolocking door to listen to whether the alarm goes off. Employee E3 confirmed that each resident wearing a wander guard is pushed in a wheelchair or walked past an autolocking door on the 7:00 a.m. to 3:00 p.m. shift (day shift), the 3:00 p.m. to 11:00 p.m. shift (evening shift) and the 11:00 p.m. to 7:00 a.m. shift (night shift) to confirm function and placement by listening for the alarm to sound. Employee E3 was not aware of a user manual for the wander guard device. Review of medical records and care plans for Residents R7, R15, R69, R73 and R91 revealed that these five residents were identified as at risk of eloping from the facility and that elopement precautions were to be in place. Continued review of the medical records revealed that the wander guard placement checks was signed off by the licensed nurses assigned to the residents, not by the charge nurses, as stated by Employee E3, RN, nurse manager. Additionally, the function checks ordered by the physician were for weekly assessment on evening shift, not on every shift. Observation of a wander guard door test at an end-of-hallway fire exit door with Employee E3, RN, nurse manager, on (MONTH) 6, 2019, at 12:41 p.m. revealed that the employee was able to open the fire exit door without a code and access the stairwell without triggering any wander guard alarms. Interview with Employee E13, RN, nursing supervisor for the second-floor evening shift, on (MONTH) 6, 2019, at 4:10 p.m. revealed that the only way to check the wander guard function was by pushing residents past the autolocking wander guard central core stair door and listening for the alarm to sound. Employee E13 stated there was no machine to check the function of the wander guard devices on the residents. Interview with Employee E14, Registered Nurse, on (MONTH) 6, 2019, at approximately 4:30 p.m. revealed that the employee routinely works on the evening shift (3:00 p.m. to 11:00 p.m.). Employee E14 indicated that for any resident who wears a wander guard device, the employee would check for the physical presence of the wander guard device on the resident. The employee then would document verification of placement on the resident's treatment administration record (TAR) every shift. Further interview with Employee E14 revealed that it was the employee's understanding that the evening shift nursing supervisor would check the funtion of the residents' wander guard devices. Interview with the unit manager on the third-floor on (MONTH) 7, 2019, at 11:00 a.m. confirmed that the elevator did not alarm when someone with a wander guard went by. An interview with the NHA on (MONTH) 7, 2019, at 2:00 p.m. revealed that the elevators alarm when a resident with a wander guard goes near them. Further interview with NHA on (MONTH) 8, 2019, at 9:00 a.m. confirmed that she was mistaken, the elevator was not alarmed and it will not alarm when a resident with a wander guard goes near the elevator. Later interview with the NHA on (MONTH) 8, 2019, at 2:20 p.m. confirmed that the elevators do not have wander guard autolocking sensors and that some staff were trained that the elevators did have alarms and other staff were trained that they did not have alarms. Observation on (MONTH) 6, 2019, at 10:00 a.m. revealed the fire alarm for the building sounded. Interview with the Nursing Home Administrator (NHA) on (MONTH) 6, 2019, at 10:15 a.m. with the Nursing Home Administrator (NHA) revealed that the fire alarm was triggered by construction dust. Review of the facility policy titled Master Fire Plan and dated (MONTH) 2019 revealed that the Fire Captains (fire captain- individual in charge of the maintenance of fire fighting equipment) on day shifts are the nurse on the second- and third-floor B- and C-wings respectively. Interview with the DOM on (MONTH) 6, 2019, at 2:02 p.m. revealed that the fire exit doors did not have wander guard detector sensors on them. The DOM confirmed that the doors at the bottom of the fire staircases exit to the outside of the facility and did not have wander guard detectors on them. The DOM further stated that the fire exit doors should have been secured with magnetic locks and were not at this time. Interview with the NHA and Director of Nursing (DON) on (MONTH) 6, 2019, at 3:03 p.m. revealed that the fire captains on both nursing units did not perform checks to ensure the fire doors were securely locked after the fire alarm was lifted in the morning and had not received formal instruction in this process. Review of the facility policy titled Master Fire Plan and dated (MONTH) 2019 revealed that the Fire Captains did not have explicitly prescribed roles. A request for written information detailing the role of the Fire Captain on (MONTH) 6, 2019, at 2:46 p.m. to the NHA and DON was not fulfilled, and no Fire Captain competencies were provided. Further interview with the NHA on (MONTH) 8, 2019, at 2:23 p.m. revealed confirmation that the facility did not have a standardized training or competency assessment in place to train and test the knowledge of all nursing staff in how to correctly check the placement and function of the wander guard, to check wander guard door function, to check fire door function after fire alarms. The NHA also confirmed the facility had no process in place to document according to manufacturer guidelines that the wander guard tag serial number, the test date, the test method (handheld reader or door), the test result (OK or not working) and who had completed the test. The facility failed to ensure that nursing staff had the appropriate skill set to provide the necessary care and services to residents identifed as at risk for elopement. Additionally, the facility failed to ensure that staff had the necessary training to competently fill the role of fire captain. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/19/18, 09/21/17 28 Pa. Code 201.18(b)(1) Management Previously cited 07/19/18, 09/21/17 28 Pa. Code 201.18(b)(3) Management Previously cited 09/21/17

Based on observations, review of facility policies, clinical records and investigative information, and staff interviews, it was determined that the facility staff failed to provide supervision or support to prevent accidents for four of nineteen residents reviewed (Resident CL1, CL5, R9, CL4) which resulted in actual harm to Resident CL1 and the facility failed to ensure a safe environment for residents related to the security of the laundry chute doors and the storage closet doors for two of 2 nursing units (the Second and Third Floor Nursing Units). Findings include: Review of the facility's policy and procedure titled, Mechanical Lift - Full Body Lift, dated April 11, 2006, revealed that the use of mechanical lifts requires the assistance of two persons at all times. Review of Resident CL1's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident CL1's care plan revealed that for transfers utilizing a mechanical lift, the resident required a full body lift with staff assistance of two for transfers. Review of Resident CL1's clinical record progress note dated October 8, 2016, revealed that Resident CL1 fell from the full body lift. The resident was found lying on his/her left side with a large amount of blood underneath him/her. A review of the facility's internal investigation employee statement (no date) revealed Employee E8, NA (Nursing Assistant), observed the, . black strap on the left was coming off and the resident fall fast face first on the ground . A review of the facility internal investigation employee statement dated October 8, 2016, revealed that Employee E9, Registered Nurse stated, . CNA (nursing assistant) reported res (resident) fell from full body lift. Found resident lying on (his/her) left side with large amt. of blood underneath (him/her). Full body lift was above resident. Res was moving R (right) hand. Res was moaning . A review of the facility internal investigation employee statement dated October 8, 2016, written by Employee E10, a Registered Nurse (RN), revealed, At approx 9:30 AM I was called by nursing assistant, (Employee E11, NA) to summon me because resident had experienced a 'terrible fall.' I immediately went to (the room) and found resident, (Resident CL1) lying on the floor on (his/her) left side. (His/Her) legs were flexed. A very large amount of blood was seen under (his/her) head. (He/She) was softly moaning - did not respond to verbal stimuli. Arms were also flexed - unable to obtain a blood pressure because we could not extend (his/her) arm. The full body lift was positioned over (him/her). Three straps were attached to the sling - one was not. (Employee E8, NA) was present in the room. (He/She) fell out of the sling when I was moving (him/her). Employee E8, NA stated that another NA was present at the time of transfer. The NA that he/she claims to have been present when Employee E11, NA who later denied that he/she was present during the lift procedure. A review of the facility internal investigation employee statement (no date) revealed Employee E11, NA, revealed, Today October 8, 2016 around 9:15 am I was heading on my 15 minute break when I was asked to help (NA, Employee E8) with a resident. Upon entering the room, through the ajoining (sic) room's bathroom, I saw the full body body lift parallel to the bed. It was fully lifted, legs apart with the boom facing the window. Three of its four straps were still connected to the lift. The fourth unconnected strap was the bottom left strap. (Resident CL1) was also parallel to the bed, (him/her) head was facing the window, (he/she) was face down in a pool of blood on the floor. The nursing assistant (Employee E8, NA) approached me, and asked me to say that I was in the room assisting (him/her) during the incident. I declare I was not; I witnessed only the results of what transpired in (Resident CL1's) room, after the fact. A review of the facility internal investigation employee statement dated October 8, 2016, dictated to Employee E10, RN, from Employee E12, NA, revealed, . I was coming out of a resident's room to go to kitchen and I saw (Employee E11, NA) about to go on elevator. (Employee E11, NA) and I were both approached by (Employee E8, NA) who said, I need help! (Employee E11, NA) and I followed (him/her) to go to (the residents room) but we had to gain access to the room by going through the adjoining bathroom. (Employee E8, NA) was the first person in the room followed by (Employee E11, NA) and then me. I could see that (Resident CL1) was lying on the floor in a pool of blood. I did not go in the room because I was so upset by what I saw. I returned to my other resident's room. Shortly after I returned to (his/her) room, (Employee E11, NA) came into the room and stated I cant' do it, I can't do it. When I asked (him/her) what (he/she) meant, (he/she) said, (Employee E8, NA) wants me to say that I was assisting (him/her) with the lift but I was not. I replied, No! you can't put yourself in that situation . Review of Resident CL1's clinical record progress note dated October 10, 2016, revealed that Resident CL1 was transferred to the hospital due to the fall from the lift on October 8, 2016, and Resident CL1 passed away on October 9, 2016. Review of the information dated October 12, 2016, submitted by the facility revealed the description of the incident which included that Resident CL1 was admitted to the hospital with [REDACTED]. In addition, the findings of the facility's investigation revealed that Employee E8 did not follow the facility policy, Mechanical Lift-Full Body which states that the use of mechanical lifts requires the assistance of two persons at all times. Employee E8, prior to Resident CL1's fall, had received formal education and training related to the two person mechanical lift and the resident's Kardex (a nurse aide instruction sheet detailing the resident's care) and transfer status. An interview on October 31, 2016, at approximately 3:35 p.m. with Employee E1, the Executive Director, confirmed the facility's policy, Mechanical Lift - Full Body Lift which stated that the use of mechanical lifts requires the assistance of two persons at all times and in addition, Resident CL1's care plan stated for resident transfers, to utilize a mechanical lift and the resident required a full-body lift with two staff assistance for transfers. Employee E1 confirmed that Resident CL1's fall from the full body lift, where Resident CL1 was transferred and admitted to the hospital with [REDACTED]. Employee E1 confirmed the outcome of the facility's investigation had revealed that Employee E8 attempted to transfer the resident via a full-body lift by himself/herself. Employee E1 confirmed that the findings of the facility's investigation revealed that Employee E8 asked Employee E11 to lie and say that Employee E11 was present during Resident CL1's attempted transfer and fall where Employee E11 came forward and exposed Employee E8's attempted cover up. Employee E1 confirmed that the findings of the facility's investigation revealed that Employee E8 did not follow the facility policy, and had received formal education and training related to using two people with the mechanical lift, the resident Kardex and transfer status. Review of Resident CL5's clinical record revealed the resident had [DIAGNOSES REDACTED].), dementia (a group of thinking and social symptoms that interferes with daily functioning) and muscle weakness (extra effort is required to move your arms, legs, or other muscles). Review of Resident CL5's clinical record care plan revealed that the resident was a fall risk and as an intervention the resident was assigned a one to one observation (increased level of observation, where a staff member is assigned to monitor a resident) where the NA would not leave the room. Review of Resident CL5's clinical record progress note dated August 6, 2016, revealed that the resident was found sitting on the floor between the recliner and the bed with their feet out in front of him/her. The resident sustained [REDACTED]. A review of the facility's internal investigation employee statement dated August 8, 2016, revealed that Employee E5, a NA, was assigned as Resident CL5's one to one observer. Employee E5 had left Resident CL5's room to care for another resident. Employee E5 had exited Resident CL5's room and, heard a bang, which was identified as the sound of Resident CL5 falling. An interview on October 31, 2016, at approximately 4:55 p.m. with Employee E1 confirmed that Resident CL5 was a fall risk and as an intervention, the resident was assigned a one to one observation staff member, where the NA would not leave the room. Employee E1 confirmed that Employee E5 was assigned as Resident CL5's one to one observer and left Resident CL5's room and Resident CL5 had fallen, sustaining a bruise and a skin tear. Review of Resident R9's clinical record revealed the resident had [DIAGNOSES REDACTED]. to move your arms, legs, or other muscles), abnormalities of gait and mobility (a deviation from normal walking), [DIAGNOSES REDACTED] (a nervous system disorder that causes rhythmic shaking) and a nondisplaced bimalleolar (boney prominence on each side of the ankle) fracture of the right lower leg. Review of Resident R9's clinical record care plan revealed an Activities of Daily Living (ADL) self-care performance deficit and as an intervention, the resident could walk with a rolling walker with two staff members assisting the resident with walking. Review of Resident R9's clinical record progress note dated August 7, 2016, revealed that Resident R9 had a fall that was witnessed by the staff, where Resident R9 sustained a 1 cm x 0.2 cm linear (in a straight line) abrasion (superficial damage to the skin) to Resident R9's left side of the bridge of his/her nose. A review of the facility's internal investigation employee statement (no date) revealed that Employee E6, a NA, assisted Resident R9 to the bathroom using a walker by him/her self with no other staff assisting. The resident had fallen and sustained the above mentioned injury. An interview on October 31, 2016, at approximately 4:45 p.m. with Employee E1 confirmed Resident R9's care plan had an Activities of Daily Living (ADL) self-care performance deficit focus area and as an intervention the resident could walk with a rolling walker with two staff members assisting the resident with walking. Employee E1 confirmed that Employee E6 assisted Resident R9 to the bathroom using a walker by him/her self with no other staff assisting and the resident had fallen and sustained an injury to the bridge of the nose. Review of Resident CL4's clinical record revealed the resident had [DIAGNOSES REDACTED]. function that causes the sudden need to urinate), had an artificial knee joint (bone and cartilage are removed and replaced with metal components), asthma (difficulty in breathing) and osteoarthritis. Review of Resident CL4's clinical record care plan revealed a focus area for toileting, where the resident required total assistance by two staff for toileting. The resident used a full body lift for transfers and the resident needed the assistance of two staff members for clothing management with toileting. Review of Resident CL4's clinical record progress note dated September 13, 2016, revealed Employee E7, a NA, was heard calling for assistance. Employee E7 was noted to be in front of Resident CL4 holding the resident upright against an electric wheelchair to prevent the resident from falling. Resident CL4 was not able to sit back into the wheelchair and needed to be lifted by three staff members into a seated position. Resident CL4 reported he/she had to bear weight longer on his/her right leg than he/she usually can bear and complained of pain. Review of Resident CL4's clinical record interdisciplinary progress note dated September 15, 2016, revealed Resident CL4 had a near fall on September 13, 2016, when being toileted by one staff member. The resident was an assist by 2 staff members. The resident was unable to stand for a long period of time. An interview on October 31, 2016, at approximately 4:00 p.m. with Employee E1 confirmed Resident CL4's care plan focus area for toileting included the resident required total assistance by 2 staff members for toileting. The resident used a full body lift for transfers and the resident needed the assistance of 2 staff members for clothing management with toileting. Employee E1 confirmed that Resident CL4 had a near fall on September 13, 2016, where Resident CL4 had to bear weight longer on his/her right leg than he/she usually could and complained of pain related to being assisted by one staff member, whereas the resident was an assist by 2 staff members. The facility failed to ensure that staff followed residents' care planned observation and transfer procedures in order to prevent neglect. Observation during the initial tour of the Second and Third Floor Nursing Units on October 27, 2016, from 8:50 - 9:55 a.m. revealed the following: The laundry chute door on the Second and Third Floor Nursing Units were not locked on each floor. An interview with Employee E4, the Director of Housekeeping, on October 27, 2016, at 9:55 a.m. confirmed that the laundry chute doors were not locked as they should be. Observations during the initial tour of the Second and Third Floor Nursing Units and for the remaining days of the survey, (October 27, 28, 31 and November 1, 2016), revealed that the doors for the biohazard (infectious waste) and the trash closets were not locked during various times on each day of the survey. Also observed during the initial tour of the Second and Third Floor Nursing Units and for the remaining days of the survey, it was revealed that the door to the oxygen tank storage closet was not locked during various times on each day of the survey. An interview with Employee E4 on October 27, 2016, at 9:55 a.m. at the end of the initial tour of the Second and Third Floor Nursing Units, confirmed that the laundry chute doors were not locked. During an interview with the Director of Nursing on November 1, 2016, at 11:30 a.m. it was confirmed that the closet doors for the biohazard/trash and the oxygen were not locked. The Director of Nursing further indicated that the closet doors to these areas and the laundry chutes should be locked at all times. The facility failed to ensure that a safe environment was maintained by keeping the laundry chute doors and the biohazard/trash and oxygen closets locked at all times. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 06/01/16 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 06/01/16, 09/16/16

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide adequate assistance to one of six residents reviewed, resulting in actual harm to the resident (Resident CL1). Findings include: Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on [DATE], with diagnoses, including but not limited to, CVA (cerebral vascular accident-stroke), right sided [DIAGNOSES REDACTED] (extreme weakness or paralysis to one side of the body), aphasia (severely impaired or absent speaking ability) and dementia (progressive degenerative disease of the brain resulting in a loss of function and contact with reality). Further review of Resident CL1's clinical record revealed an Admission Summary, note dated May 9, 2016, at 2:45 p.m., which stated that the resident was awake, alert and oriented times two (aware of person and place but unaware of time) with confusion. and Assist times two (two staff members) with ADLs (Activities of daily living- tasks such as dressing, grooming and toileting) and transfers (moving from one area to another). In addition, a Morse Fall Scale (Fall risk assessment tool) form dated May 9, 2016, indicated that the resident had a prior history of falling, was weak and over-estimated or forgot one's own physical limitations. Resident CL1's total score for the Morse Fall Scale was 65 which reflected that the resident was at increased risk for falling. An individualized plan of care developed for Resident CL1, dated May 9, 2016, identified the resident as a fall risk and instructed staff to transfer the resident with two staff members. Additional nursing documentation dated May 12, 2016, at 1:53 p.m., revealed that Resident CL1's had fallen on May 11, 2016, at approximately 12:45 p.m Immediately following the fall, the resident experienced pain in the right hip and was subsequently transferred to the hospital, where the resident was diagnosed with [REDACTED]. Interview with Employee E2, director of nursing, on June 1, 2016, at 8:15 a.m., revealed that the facility had conducted an internal investigation into the details of Resident CL1's fall on May 11, 2016. Further interview with Employee E2 revealed that the investigation had determined that Resident CL1 had been transferred to the bathroom by one staff member while the plan of care for this resident had determined that the resident required the assistance of two staff members for all transfers. The facility failed to ensure that one resident, identified as at increased risk for falls, received the necessary assistance to safely transfer to the bathroom resulting in actual harm to Resident CL1. 28 Pa Code: 211.10(d) Resident care policies. 28 Pa Code: 211.12 (d)(1)(5) Nursing services.