Every finding on record at St Barnabas Nursing Home

Based on review of facility policy, resident clinical records, facility provided documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R3).Findings include: Review of facility policy Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property dated 12/9/25, indicated all allegations of abuse must be reported initially through the Electronic Event Reporting system (ERS). Emotional or psychological abuse - the verbal or nonverbal infliction of anguish, pain or distress that results in mental or emotional suffering. Taking or using photos or recordings in any manner that would demean or humiliate a resident. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE], with the diagnoses of right humeral fracture (a break in the upper arm bone), pain, and high blood pressure. Review of Behavior Night Shift Documentation dated 3/8/26, indicated Resident R3 called 911 and was attempting to take photos of other residents without their consent. Interview on 3/11/26, at 10:30 a.m. Resident R3 indicated everything was fine until resident called the police and the facility turned everything around on resident and removed resident's roommate Resident R4 out of the room. Interview on 3/11/26, at 12:00 p.m. the Director of Nursing indicated Resident R4's family indicated to Resident R3 to watch out for their loved one. Resident R3 took that statement too seriously and was photographing Resident R4. Resident R4 always had full clothing on in the photos. Review of the facility's ERS reports failed to include a report of alleged abuse as required. Interview with the Director of Nursing on 3/11/26, at 1:00 p.m. indicated the facility didn't realize it was reportable and failed to report an allegation of abuse for one of three residents (Resident R3). 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of three sampled residents (Resident R1).Findings include: Review of the facility policy Behavioral Management Programs dated 12/9/25, indicated the facility will provide behavioral management programs for those patients who exhibit behavioral problems that will maximize their psychosocial well-being. The program will promote non-medical interventions. Implemented for those patients with a recurring behavior that is deviant from that which is commonly regarded as acceptable by normal standards. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), cognitive impairment of unknown etiology, and Parkinson's Disease (disorder of the nervous system that results in tremors). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) score of two - severe cognitive impairment. Section Behaviors - E0200 indicated C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1. Behavior of this type occurred one to three days. Review of Resident R1's current care plan indicated the resident has a potential for behavioral problem due to cognitive impairment. The resident will have no evidence of behavior problems such as sexually inappropriate towards staff by review date. Interventions included:-Anticipate and meet the resident's needs.-Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.-Praise any indication of the resident's progress/improvement in behavior. Review of Activity Interview for Daily and Activity Preferences dated 1/24/26, indicated:- it was somewhat important for Resident R1 to have books, newspapers, and magazines to read. -it was very important to listen to the music they like.-it was very important to be around animals such as pets.-it was very important for resident to do their favorite activities.-it was very important to go outside to get fresh air when the weather is good. Review of Resident R1's Behavior Day Shift Documentation dated 1/25/26, indicated numerous attempts to disrobe in the hallway. Review of Resident R1's Behavior Day Shift Documentation dated 2/13/26, indicated exposing and manipulating penis. Review of facility provided documentation dated 2/13/26, indicated Resident R2 stated while they were placed in the dining room area by a Physical Therapist, a male resident (Resident R1) was behaving inappropriately. Our review of the allegation regarding the male resident determined that the individual in question has advanced dementia and lacks awareness of their surroundings. On one occasion, Resident R1 was observed at the nurses' station with clothing displaced due to confusion. Review of progress note dated 2/13/26, at 7:51 a.m. indicated patient reports that they are upset after seeing another resident perform masturbation in the common area. This has been reported to nursing and administration. Observation on 3/11/26, at 9:30 a.m. Resident R1 was observed at the nurses' station in a reclining medical wheelchair placed at the desk beside the Unit Secretary Employee E1. There was nothing provided to Resident R1 for stimulation or diversional activity. Interview with Unit Secretary Employee E1 on 3/11/26, at 10:28 a.m. indicated their position was non-medical in nature and they sat with Resident R1 to watch them. Interview on 3/11/26, at 10:32 a.m. Registered Nurse (RN) Employee E2 indicated Resident R1 disrobes frequently, at times manipulates his penis and staff try to redirect resident but aren't always successful. Also indicated staff can't leave resident in the room because resident is a fall risk. Interview on 3/11/26, at 12:09 p.m. Nurse Aide (NA) Employee E3 indicated Resident R1 removes their clothes daily, sometimes manipulates penis and pulls it out of the clothing. Resident R1 also behaves this way when resident's spouse is present. Interview on 3/11/26, at 2:00 p.m. the Director of Nursing confirmed the facility failed to ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of three sampled residents (Resident R1). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on review of facility policy, resident records and staff interview, it was determined that the facility failed to make certain that medical records on each resident were complete and accurately documented for one of five residents (Resident R46).Findings include: Review of the facility Medication Administration policy dated 12/9/25, revealed medications shall be administered by the same licensed nurse who prepared the dose for administration and will give as soon as possible after being prepared. Refer to electronic record for Medication Administration. Nurse is responsible for noting any changes on Medication Administration Record. If a resident refuses medication, indicated on Medication Administration Record. Once removed from the package or container, unused doses should be discarded. Review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. Review of Resident 46's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/26/25, indicated diagnoses of high blood pressure, paraplegia, and pain disorder with related psychological factors. Review of Resident R46's clinical record revealed physician order dated 7/21/25, to administer 5 milligram, (mg) oxycodone every six hours as needed for pain disorder with related psychological factors, one tablet by mouth every six hours for moderate to severe pain 5-10. A review of Resident R46's Controlled Drug Record revealed LPN, Employee E8 signed out the resident's 5 mg oxycodone on the following days:-12/4/25, at 9:00 a.m. -12/5/25, at 10:00 a.m.-12/10/25, at 9:50 a.m.-12/13/25, at 9:00 a.m.-12/19/25, at 9:00 a.m.-12/20/25, at 10:15 a.m.-12/24/25, at 8:15 p.m.-12/26/25, at 8:00 p.m.-12/27/25, at 9:00 a.m.-12/28/25, at 9:00 a.m.-12/29/25, at 8:00 a.m. A review of Resident R46's December 2025 Medication Administration Record failed to reveal evidence Resident R46's 5 mg oxycodone was administered for the following days:-12/4/25, at 9:00 a.m. -12/5/25, at 10:00 a.m.-12/10/25, at 9:50 a.m.-12/13/25, at 9:00 a.m.-12/19/25, at 9:00 a.m.-12/20/25, at 10:15 a.m.-12/24/25, at 8:15 p.m.-12/26/25, at 8:00 p.m.-12/27/25, at 9:00 a.m.-12/28/25, at 9:00 a.m.-12/29/25, at 8:00 a.m. During an interview on 2/5/26, at 10:56 a.m. Registered Nurse Staff Development, Employee E9 stated That's nursing 101, you don't sign off until you give it. During an interview on 2/5/26, at 11:08 a.m. the Director of Nursing confirmed the facility failed to make certain that medical records on each resident were complete and accurately documented for one of five residents (Resident R46). 28 Pa. Code: 211.5(f) Clinical records.

Based on review of clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain hearing ability for one of two residents (Resident R30). Findings include: Interview on 2/4/26, at 2:30 p.m. the Nursing Home Administrator indicated the facility did not have a policy for treatment and assistive devices to maintain hearing ability. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/14/25, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and anxiety. Section B0200 indicated ability to hear as highly impaired. Review of Resident R30's physician orders failed to include use and management of an amplifier. Review of Resident R30's care plan indicated the resident has a potential for communication problem related to hearing deficit. Interventions included speaking on an adult level, speaking clearly and slower than normal. Amplifier use and management failed to be addressed in the care plan. Observation on 2/2/26, at 9:30 a.m. Resident R30 was noted to be awake and lying in the bed. Interview on 2/2/26, at 9:30 a.m. Resident R30 motioned with hands to the bedside dresser's top drawer and said, Get my headphones out of the drawer for me. Observation and interview of Resident R30 placing the headphones on the head over the ears and turning on the box wired to the headphones. Stated, I can hear you now. Interview on 2/4/26, at 10:51 a.m. Nurse Aide (NA) Employee E2 indicated I just speak loudly and slowly with Resident R30 when asked how staff communicate with resident. Interview on 2/4/26, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that residents receive proper treatment and assistive devices to maintain hearing ability for one of two residents (Resident R30). 28 Pa. Code: 211.10(a)(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change (Resident R6) and failed to implement Enhanced Barrier Precautions for two of three residents (R6 and R35).Findings include: A review of facility policy Infection Prevention and Control Programs dated 12/9/24, indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of facility policy Enhanced Barrier Precautions dated 12/9/25, indicated the facility will adhere to CDC guideline recommendations for the use of Enhanced Barrier Precautions (EBP) when providing care to residents identified as at risk for multi-drug-resistant organisms (MDRO) or to those residents identified as having a MDRO infection. Appropriate PPE will be obtained for EBP. Care Plan will be updated to include EBP. Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/23/25, indicated diagnoses of adult failure to thrive, dehydration, and non-Alzheimer's dementia (the significant loss of memory and cognitive abilities, impacting personal, social, or occupational functions).Section M: Skin Conditions revealed the resident had one unstageable pressure ulcer. Review of Resident R6's progress note dated 2/3/25, revealed the resident had a left heel unstageable pressure injury. During an observation on 2/4/26, at 11:25 a.m. no Enhanced Barrier Precaution signage was posted at the entrance of Resident R6's door. A review of Resident R6's physician orders on 2/4/26, failed to include an order or care plan for EBP. During an observation of Resident R6's dressings change on 2/4/26, at 11:27 a.m. the following was observed:Registered Nurse (RN), Employee E12 failed to clean and disinfect the bedside table. RN, Employee E12 placed all items including gloves and the dressing on the bedside table. RN, Employee E12 failed to apply a barrier to the table and prevent cross contamination. During an interview on 2/4/26, at 11:35 a.m. RN, Employee E12 confirmed the bedside table was not cleaned or disinfected and a barrier was not applied. RN, Employee E12 confirmed the facility failed to maintain proper infection control practices and prevent cross contamination. RN, Employee E12 confirmed Resident R6 was not ordered EBP. Review of the clinical record revealed Resident R35 was readmitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of orthopedic aftercare, chronic kidney disease, and constipation. During an observation on 2/2/26, at 12:43 p.m. no Enhanced Barrier Precaution signage was posted at the entrance of Resident R6's door Review of Resident R35's progress note dated 2/3/25, revealed the resident had a stage two left heel pressure injury. Review of Resident R35's physician orders on 2/3/25, failed to include an order or care plan for EBP. During an interview on 2/4/26, at 2:02 p.m. Infection Preventionist, Employee E13 confirmed the facility failed to implement EBP for Resident R6 and Resident R35's pressure ulcers. During an interview on 2/4/26, at 2:05 p.m. the Director of Nursing confirmed that the facility failed to prevent cross contamination during a dressing change (Resident R6) and failed to implement Enhanced Barrier Precautions for two of three residents (R6 and R35). 28 Pa. Code: 211.10(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure residents were transported safely in wheelchairs for one of three residents (Residents R49) and failed to ensure residents were assessed by a Registered Nurse (RN) prior to moving the resident after a fall for one of three residents (Resident R51).Findings include: Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident 49's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/4/26, indicated diagnoses of non-Alzheimer's dementia (the significant loss of memory and cognitive abilities, impacting personal, social, or occupational functions), seizure disorder (characterized by abnormal electrical activity in the brain, leading to changes in awareness and muscle control.), and multiple sclerosis (a chronic autoimmune disorder that affects the central nervous system, specifically the brain and spinal cord). During an observation on 2/5/26, at 10:22 a.m. Resident R49 was observed being pushed down the hallway in a wheelchair without leg rests by Recreation Director, Employee E10. During an interview on 2/5/26, at 10:24 a.m. Recreation Direction, Employee E10 confirmed she was pushing resident R49 in a wheelchair without leg rests. During an interview on 2/5/26, at 12:04 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide a safe environment for one of four residents (Resident R49). Review of the facility policy Events dated 12/9/25, indicated all injuries or events will be assessed by trained staff. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (the blood doesn't have enough healthy red blood cells), and blindness in the left eye. Review of Resident R51's progress note dated 12/12/25, at 3:38 p.m. indicated resident was receiving a shower this morning around 9:00 a.m. Resident was transferring from shower chair to wheelchair and was holding on to the grab bar when she stated her grip was weak and then her knees gave out. The aids lowered her to the ground in a sitting position while the other aid went to get help. Resident was transferred to wheelchair. No injuries or pain noted. After NA's had another staff member to help assist stand resident and transfer into wheelchair. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement indicated they were informed by NA that after the shower the resident stood up holding the bar and the knees gave out. NA lowered resident to the ground sitting on the coccyx. The NA went and got help from another NA to stand the resident to put resident in the chair. Interview with the Director of Nursing on 2/5/26, at 2:00 p.m. indicated the facility could not provide documented evidence that Resident R51 was assessed by a Registered Nurse prior to the NA's moving the residents' position after a fall. Interview on 2/5/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to ensure residents were transported safely in wheelchairs for one of three residents (Residents R49) and failed to ensure residents were assessed by a Registered Nurse (RN) prior to moving the resident after a fall for one of three residents (Resident R51). 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policy, facility documents, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of five residents (Resident R46).Findings include: Review of the facility policy Prohibition and Prevention of Resident Abuse, Neglect, Exploitations, Mistreatment, or Misappropriation of Resident Property dated 12/9/25, indicated residents are protected and to ensure the safety and security of residents who are involved in misappropriation of resident property. Review of the facility policy Narcotic Count Education dated 12/9/25, indicated if a discrepancy if found, recheck the numbers, check the resident's order sheers and chart to see if a narcotic has been administered and not recorded., Check previous recording on the control sheets for mistakes in arithmetic. If the causes of the discrepancy cannot be located and/or the found does no balance, report the matter to the Director of Nursing. Review of Licensed Practical Nurse (LPN), Employee E5's signed job description dated 7/18/24, indicated the LPN will carry out nursing care actions which promote, maintain, and restore the well-being of residents. Review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. Review of Resident 46's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/26/25, indicated diagnoses of high blood pressure, paraplegia, and pain disorder with related psychological factors. Review of report submitted on 1/6/26, revealed Resident R46's 30-count card of 5 milligram (mg) oxycodone was missing an unaccounted for. The nurse on duty, during her medication pass, discovered and recognized the discrepancy based on her prior verification and signature acknowledging receipt of three 30-count cards of oxycodone at the time of pharmacy delivery on a previous night that she was on duty. The nurse subsequently checked the cards again and observed that only two of the three cards, were present in narcotic drawer on 1.6.26. Upon review the physical narcotic count on remaining cards was accurate and consistent with the medication present in card, however the absence of the third card could not be explained. Review of a written statement dated 1/8/26, revealed that Licensed Practical Nurse (RN), Employee E6 wasted another resident's medication on 1/2/26, and then counted at 7 a.m. and both narcotic boxes were the correct count in both medication carts. Review of a written statement dated 1/7/26, revealed RN, Employee E7 counted the narcotics with LPN, Employee E6 on 1/2/26. The narcotic count sheet was present in the narcotic book. On Monday, I noticed that Resident R46's number two of three oxycodone card was not in the narcotic drawer. I went to look at narcotic count sheet and it was missing. There was a blank narcotic sheet in the book with 23 written at the top. Review of a written statement dated 1/9/26, revealed that Registered Nurse (RN), Employee E4 was charge nurse on 1/4/26, from 7 a.m. to 7:30 p.m. The overnight nurse, Licensed Practical Nurse (LPN), Employee E5 was at the nursing station with her head on the desk. Asked her several times if she was ok. She woke up groggy and said Yes, I'm ok. There was only one narcotic sheet in the book that didn't have a date at the top of the page, just a number count for narcotics that matched number in chart. Asked nurse where the prior Narcotic Sheets were and was told she placed them in Assistant Director of Nursing's office. Mentioned to nurse that there should always be prior Narcotic Count Sheets in book readily to see what medications were added and subtracted. During an interview on 2/6/25, at 11:37 a.m. RN, Employee E7 stated I entered in Resident R46's three cards of oxycodone when it was delivered. Then at beginning of January, changeover month, I noticed when I was counting, the count appeared right, but Resident R46's number two of three oxycodone card was missing. I tried to look for signature pages, and the page prior was missing, and it was a blank sheet. I knew the sheet prior was there Friday since me and another nurse wasted a resident's medication. It was indicated the narcotic sheets should never be taken or destroyed. During a phone interview on 2/6/25, at 11:31 a.m. LPN, Employee E6 was not available. During a phone interview on 2/6/25, at 11:45 a.m. LPN, Employee E5 was not available. During an interview on 2/5/26, at 10:35 a.m. the Nursing Home Administrator stated LPN, Employee E5 refused to return to facility for witness statement or drug test and was terminated. During an interview on 2/5/26, at 12:04 p.m. the NHA and Director of nursing confirmed the facility failed to ensure that residents are free from misappropriation of medication for one of five residents (Resident R46). 28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of three allegations of abuse for one of five residents (Resident R46).Findings include: Review of the facility policy Prohibition and Prevention of Resident Abuse, Neglect, Exploitations, Mistreatment, or Misappropriation of Resident Property dated 12/9/25, indicated residents are protected and to ensure the safety and security of residents who are involved in misappropriation of resident property. Assure a timely, thorough, and objective investigation of all allegations of misappropriation of resident property is completed. Review of the facility policy Narcotic Count Education dated 12/9/25, indicated if a discrepancy if found, recheck the numbers, check the resident's order sheers and chart to see if a narcotic has been administered and not recorded., Check previous recording on the control sheets for mistakes in arithmetic. If the causes of the discrepancy cannot be located and/or the found does no balance, report the matter to the Director of Nursing. Review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. Review of Resident 46's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/26/25, indicated diagnoses of high blood pressure, paraplegia, and pain disorder with related psychological factors. Review of report submitted on 1/6/26, revealed Resident R46's 30-count card of 5 milligram (mg) oxycodone was missing an unaccounted for. The nurse on duty, during her medication pass, discovered and recognized the discrepancy based on her prior verification and signature acknowledging receipt of three 30-count cards of oxycodone at the time of pharmacy delivery on a previous night that she was on duty. The nurse subsequently checked the cards again and observed that only two of the three cards, were present in narcotic drawer on 1.6.26. Upon review the physical narcotic count on remaining cards was accurate and consistent with the medication present in card, however the absence of the third card could not be explained. During a review of the facility's investigation, it was revealed Licensed Practical Nurse, Employee E8 signed out Resident R46's 5 milligram (mg) oxycodone a total of 11 times in December 2025 without documenting the medication was administered in the resident's Medication Administration Record (MAR). A further review of the facility's investigation failed to include a witness statement from LPN, Employee E8. During an interview on 2/5/26, at 12:04 p.m. the NHA and Director of nursing confirmed that the facility failed to conduct a thorough investigation and obtain all witness statements for one of five residents (Resident R46). 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights. 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of five residents (Resident R50 and R51). Findings include: Review of Resident R50's admission record indicated she was admitted on [DATE]. Review of Resident R50's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/21/25, indicated that she had diagnoses included left humorous fracture, hypertension (a condition impacting blood circulation through the heart related to poor pressure), Alzheimer's dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry) and hypothyroidism (a decrease in production of thyroid hormone). Review of Resident R50's MDS assessment completed 11/21/25, Section N0415-High risk drug classes Part A indicated an X meaning that Resident R50 was using an antipsychotic medication within the last seven days. Review of Resident R50's care plan dated 11/7/25, indicated she will remain free of depression symptoms, anxiety symptoms, and to administer medications as ordered. The care plan gave no mention of Resident R50 receiving antipsychotic medications. Review of Resident R50's medications and physician orders dated 11/7/25 to 2/4/26, did not include an anti-psychotic medication. Review of Resident R50 Medication Administration Record (MAR) for November 2025 did not include the use of anti-psychotic medication. During an interview on 2/4/26, at 10:56 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to ensure Minimum Data Set assessment (MDS) accurately reflected the Resident R50's status as required. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025, indicated the following instructions: -Section J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent. Coding instructions code 0, no: if the resident has not had any fall since the last assessment. Code 1, yes: if the resident has fallen since the last assessment. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (the blood doesn't have enough healthy red blood cells), and blindness in the left eye. Section J180 indicated a zero for no falls since Admission/Entry or Reentry or prior assessment. Review of Resident R51's progress note dated 12/12/25, at 3:38 p.m. indicated resident was receiving a shower this morning around 9:00 a.m. Resident was transferring from shower chair to wheelchair and was holding on to the grab bar when she stated her grip was weak and then her knees gave out. The aids lowered her to the ground in a sitting position while the other aid went to get help. Resident was transferred to wheelchair. VSS. No injuries or pain noted. After NA's had another staff member help assist stand resident and transfer into wheelchair. Review of facility provided documentation dated 12/12/25, indicated nurse was informed that after Nurse Aide (NA) gave resident a shower two aides were transferring the resident from shower chair to wheelchair, resident's knees buckled and the NA's had to lower the resident to the floor. Interview on 2/5/26, at 1:49 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed Resident R51 had a falling episode on 12/12/25, and that the MDS dated [DATE] was inaccurately coded as no fall occurring since last assessment. Interview on 2/5/26, at 2:00 p.m. the Director of Nursing confirmed the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of five residents (Resident R50 and R51). 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for pressure ulcers for two of five residents (Resident R35 and R79).Findings include: Review of the clinical record indicated Resident R35 was originally admitted to the facility on [DATE], then readmitted [DATE] . Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/29/26, indicated diagnoses of fractur of left femur (thigh bone), secondary parkinsonism (refers to movement disorders that mimic Parkinson's disease but arise from different underlying causes, such as medications, brain injuries, or other health conditions), and chronic kidney disease. Review of Section M: Skin Conditions indicated the presence of a Stage II (partial thickness skin loss) pressure ulcer. Review of facility provided document Pressure Sore List, dated 1/27/26, indicated that Resident R35 has a Stage II pressure ulcer on their left heel. Review of Resident R35's clinical record revealed a physician's order dated 2/3/26, to cleanse left heel with warm soap and water, pat dry, apply xeroform [sterile, non-adherent occlusive dressing] (cut to fit, cover with ABD (gauze pad) and wrap with kling as needed for displacement/soilage. Review of Resident R35's clinical record revealed a physician's order dated 2/3/26, to cleanse left heel with warm soap and water, pat dry, apply xeroform [sterile, non-adherent occlusive dressing] (cut to fit), cover with ABD (gauze pad) and wrap with kling every evening shift every Tuesday, Thursday, and Saturday for skin alteration. Review of Resident R35's clinical record revealed a Skin/Wound progress note date 2/3/26, indicating left heel is a Stage II pressure ulcer; status not healed. The wound is improving. Review of Resident R35's care plan initiated 1/18/26, revealed a plan of care developed for the risk that Resident R35 may develop skin breakdown, but with no plan of care developed with goals and interventions related to Resident R35 having an actual pressure ulcer. Review of the clinical record indicated Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/26, indicated diagnoses of enterocolitis due to clostridium difficile (inflammation of the digestive tract), diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels)and high blood pressure. Review of Section M: Skin Conditions indicated the presence of a Stage I (intact skin with non-blanchable redness) pressure injury and a Stage II (partial thickness skin loss) pressure ulcer. Review of facility provided document Pressure Sore List, dated 1/27/26, indicated that Resident R79 has a Stage I pressure ulcer on their left heel and an Unstageable (wound bed covered by slough and/or eschar) pressure ulcer on their sacrum. Review of Resident R79's clinical record revealed a physician's order dated 1/23/26, to apply triad (topical treatment for managing wounds) to coccyx open area and cover with allevyn (hydrocellular foam dressing) daily after cleansing with NSS (sterile water) and patting dry every night shift for open area. Review of Resident R79's clinical record revealed a Skin/Wound progress note date 2/3/26, indicated left heel is a Stage I pressure ulcer acquired 1/27/26; the wound is resolved. Review of Resident R79's clinical record revealed a Skin/Wound progress note date 2/3/26, indicated sacral is a deep tissue pressure injury acquired 1/27/26; the wound is resolved. Review of Resident R79's care plan initiated 1/23/26, revealed a plan of care developed for the risk that Resident R79 may develop skin breakdown, but with no plan of care developed with goals and interventions related to Resident R35 having an actual pressure ulcer. During to interview on 2/4/26, at 1:18 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to develop a comprehensive care plan for pressure ulcers for two of five residents (Resident R35 and R79). 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications properly in one of three medication room (First Floor Medication Room).Findings include: Review of the facility policy Medication Storage in the Facility dated [DATE], indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secured closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an observation on [DATE], at 1:33 p.m. the First floor Medication Room had following expired supplies:-(3) 500 milliliter (ml) 0.9% Normal Saline Solution expired [DATE]-(16) IV Start Kit expired [DATE] During an interview on [DATE], at 1:41 p.m. Registered Nurse, Employee E11 confirmed that the supplies were expired. Interview on [DATE], at 1:49 p.m., the Nursing Home Administrator confirmed that the facility failed to properly store supplies in one of two medication rooms (First Floor Medication Room). 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(2)(3) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner for one of three residents (Resident R36) and the facility failed to complete initial nutrition assessments for two to seven residents (Resident R29, R49). Findings include: Review of facility policy Weight Loss Prevention dated 5/23/24, indicated Dietitian or Dietitian Tech to evaluate and make recommendations as indicated. Update MD (physician) and obtain orders as needed. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE S483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of the above order indicates this is a decrease in amount of formula to be administered. Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of a Weight Change Note dated 8/13/24, completed by Registered Dietitian (RD) Employee E1 stated, Review of monthly weight status. Per weight 8/1 120# (pounds), resident with trigger for significant weight loss for 6 months (133.5#, -10.1%). Weight stable past 3 months 116-121#. Continue current TF (tube feeding) as ordered/resident tolerates. Continue to monitor weight status for significant change. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in September 2024, October 2024, November 2024, and December 2024. The review of the clinical record failed to reveal any documentation regarding the above weight changes or any nutritional recommendations. During an interview on 1/29/25, at 9:32 a.m. RD Employee E1 stated, I was not employed at the facility between 8/20/24 and 11/6/24. I can't speak exactly to Resident R36's weight loss in September. I was notified through email communication at the beginning of November. My recommendation was to increase her tube feeding rate, but her husband dictates most of her care and had no desire to increase the tube feeding rate. When asked if it is documented in Resident R36's clinical record that her husband refused to have nutritional recommendations implemented, RD Employee E1 stated, Nobody would dare put that in. Review of the clinical record revealed Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of fracture of right femur, orthopedic aftercare and atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly). Review of Resident R29's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in October 2024, November 2024, and December 2024. Review of the clinical record revealed Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/10/24, indicated diagnoses of asthma, nonrheumatic aortic stenosis (a narrowing of the aortic valve that occurs when it doesn't open or close properly) and syncope (a sudden and brief loss of consciousness that is caused by a temporary decrease in blood flow to the brain). Review of Resident R49's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in October 2024, November 2024, and December 2024. During an interview on 1/29/25, at 9:44 a.m. RD Employee E1 confirmed that the facility failed to make certain that weight loss was identified and addressed in a timely manner for Resident R36 and the facility failed to assess two residents on admission as required (Resident R29, and R49). 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of seven staff members (Employee E7, E8, E9, E11, and E12) Findings include: Review of the facility policy Facility Assessment: Staff Training and Competencies dated 5/23/24, indicated that all new staff are trained during the orientation process on designated facility topics. A checklist is completed both on theory and skills material. A checklist is completed again annually on both theory and skills material. Review of facility provided documents and training records revealed the following staff members did not have documented training. Nurse Aide (NA) Employee E7 had a hire date of 3/12/20, failed to have QAPI education between 3/12/23, and 3/12/24. NA Employee E8 had a hire date of 4/27/17, failed to have QAPI education between 4/27/23, and 4/27/24. NA Employee E9 had a hire date of 10/23/20, failed to have QAPI education between 10/23/23, and 10/23/24. NA Employee E11 had a hire date of 11/20/22, failed to have QAPI education between 11/20/23, and 11/20/24. Registered Nurse Employee E12 had a hire date of 7/12/16, failed to have QAPI education between 7/12/23, and 7/12/24. During an interview on 1/29/25, at 2:15 p.m. the Staff Development Coordinator Employee E14 confirmed that the facility failed to provide training on QAPI for five of seven staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents (Residents R1, R18, R27, and R32). Findings include: Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/24, indicated diagnoses of hemiplegia, affecting right side (medical condition that causes paralysis or weakness on one side of the body), diabetes mellitus, and hypertension. Review of Resident R1's clinical record revealed that the resident was transferred to the hospital on 8/27/24. Review of Resident R1's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of the clinical record revealed Resident R18 was admitted to the facility on [DATE]. Review of Resident R18's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and retention of urine. Review of Resident R18's clinical record revealed that the resident was transferred to the hospital on 10/8/24. Review of Resident R18's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of the clinical record revealed Resident R27 was admitted to the facility on [DATE]. Review of Resident R27's MDS dated [DATE], indicated diagnoses of congestive heart failure, respiratory failure with hypoxia and diabetes mellitus. Review of Resident R27's clinical record revealed that the resident was transferred to the hospital on 9/1/24. Review of Resident R27's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's MDS dated [DATE]/25, indicated diagnoses of high blood pressure, hyponatremia (too little sodium in the blood), and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of Resident R32's clinical record revealed that the resident was transferred to the hospital on 1/16/25. Review of Resident R32's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on [DATE]. During an interview on 1/29/25, at 10:30 a.m. Secretary Employee E3 confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents as required. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.

Based on observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R32 and R36). Findings include: Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/1/4/25, indicated diagnoses of high blood pressure, hyponatremia (too little sodium in the blood), and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of a physician order dated 1/21/25, indicated to provide oxygen at 1 - 2 liters per minute (LPM) via nasal cannula (a lightweight tube that delivers oxygen into the nostrils) continuously. During an observation on 1/27/25, at 11:57 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During an observation on 1/28/25, at 8:57 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During an observation on 1/29/25, at 10:08 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During this observation, Registered Nurse (RN) Employee E2 confirmed that Resident R32 was receiving oxygen at 3 LPM via nasal cannula. During an interview on 1/29/25, at 10:08 a.m. RN Employee E2 confirmed that the facility failed to provide appropriate respiratory care for Resident R32. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 10/5/24, indicated to administer Ipratropium-Albuterol 0.5-2.5 mg/mL (milligrams per milliliter) inhale orally every 4 hours as needed for congestion. Review of Resident R36's January Medication Administration Record indicated the resident received Ipratropium-Albuterol on 1/4/25, 1/12/25, 1/13/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/24/25, and 1/25/25. During an observation on 1/27/25, at 9:50 a.m. a nebulizer machine (a machine used to deliver aerosolized medications) was observed on Resident R36's bedside table with the attached tubing and aerosolized face mask in a bag in the drawer. Review of Resident R36's physician orders on 1/29/25, failed to include an order to change the nebulizer tubing and aerosolized face mask. Review of Resident R36's care plan on 1/29/25, failed to include goals and interventions related to the maintenance of equipment for respiratory care and failed to include interventions for procedures to follow in the event of an adverse reaction to respiratory treatments. During an interview on 1/29/25, at 10:10 a.m. Registered Nurse (RN) Employee E2 stated, I don't think there is an order to change the nebulizer tubing, I just know they do it at night on Thursday or Fridays. During an interview on 1/29/25, at 11:16 a.m. the Director of Nursing (DON) stated, Nebulizer tubing is changed Thursday into Friday on the 11 p.m. to 7 a.m. shift, it's changed with the oxygen tubing, that's just how we do it. When asked how would a new employee or agency employee know when to change the nebulizer tubing, the DON stated, It's part of orientation and onboarding, it would be discussed then. During this interview, the DON confirmed that Resident R36 did not have a physician order to change nebulizer tubing and did not have a care plan developed for the administration of aerosolized medications. During an interview on 1/30/25, at 10:01 a.m. the DON was asked to provide the facility's policies and procedures for respiratory care and aerosolized medication therapy. During an interview on 1/30/25, at 10:54 a.m. the DON stated that the facility does not have policies related to respiratory care and aerosolized medication therapy. During an interview on 1/30/25, at 10:54 a.m. the DON confirmed that the facility failed to provide appropriate respiratory care for Resident R36. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R50). Findings include: Review of the facility policy Medication Administration) dated 5/23/24 indicated medications and biologicals shall be administered by the same licensed nurse who prepared the dose for administration and will give as soon as possible after being prepared. Review of the clinical record indicated that Resident R50 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), hypertension and macular degeneration (common eye disease that damages the macula, the central part of the retina responsible for sharp, central vision). Review of Resident R50's physician orders dated 11/23/24 indicated Synthroid (to treat hypothyroidism) Oral Tablet 50 MCG (Levothyroxine Sodium) 1 tablet orally once a day. Review of Resident R50's Medication Administration Record (MAR) indicated that 12/29/24, 12/30/24, 1/21/25 and 1/27/25, staff had documented that the drug was unavailable and not given. Resident R50 had not received the medication for four days. During an interview on 1/30/25, at approximately 11:00 a.m., the Director of Nursing confirmed that the facility failed to make certain significant medications are administered as ordered by the physician. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28Pa. Code:211.9(e)(f)(g)(h) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on staff interviews it was determined that the facility failed to employ a qualified Registered Dietitian for one of twelve months (October 2024). Findings include: During an interview with Registered Dietitian Employee E1 revealed she was employed 6/29/21-8/20/24 and didn't start PRN again till 11/6/24. Interview with Nursing Home Administrator on 1/29/25 at 11:00 a.m. indicated the facility had a Registered Dietitian 9/5/24-10/4/24. During an interview on 1/29/25 at 9:00 a.m. the Nursing Home Administrator confirmed that the facility did not employ a qualified Registered Dietitian for one of twelve months as required. 28 Pa. Code 201. 18(e)(1)(6)Management. 28 Pa. Code 211. 6(c) Dietary service.

Based on policy review, documentation review, review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (February 2024 through January 2025) and failed to implement transmission-based precautions for one of four residents (Resident R36). Findings include: Review of the facility policy Legionella Prevention dated 5/23/24, indicated the facility will utilize water management practices to reduce the risk of Legionella in the ice machines by cleaning quarterly, sanitizing, and checking monthly for cleanliness. The policy fails to mention how to prevent Legionella and other microbial growth throughout the facility. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7. Documentation and communication. Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system. -Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. -Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. -Maintains compliance with other applicable Federal, State and local requirements. Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million). Review of facility policy Contact Precautions dated 5/23/24, indicated contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident's environment. Review of facility policy Enhanced Barrier Precautions dated 5/23/24, indicated the facility will adhere to the CDC guideline recommendations for use of Enhanced Barrier Precautions (EBP) when providing care to residents identified as at risk for multi-drug resistant organisms (MDRO) or to those residents identified as having a MDRO infection. The CDC defines Enhanced Barrier Precautions as: an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and gloves during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of the facility provided water management information failed to include specific testing protocols and acceptable ranges for control measures along with a description of the facility's water system using a flow diagram. Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. During an interview on 1/28/25, at approximately 11:30 a.m. the Nursing Home Administrator and Maintenance Supervisor Employee E15 confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Section H - Bowel and Bladder, Question H0100 indicated the resident has an indwelling catheter. Section K - Swallowing/Nutritional Status, Question K05520B indicated the resident has a feeding tube. Review of Section M - Skin Conditions, Question M0300 indicated the resident has 2 Stage 4 pressure ulcers and 1 unstageable pressure ulcer. Review of a nursing progress note dated 10/10/24, stated, New orders obtained for treatment of Shingles, husband updated. Review of Resident R36's clinical record failed to reveal documentation that the resident was placed in transmission-based precautions for Shingles on 10/10/24, and failed to reveal documentation that EBP were implemented related to Resident R36's wounds and indwelling medical devices. During an interview on 1/29/25, at 10:10 a.m. Registered Nurse (RN) Employee E2 stated, I'm not sure if isolation precautions are in the physician orders or resident care plans, usually I find out by word of mouth. During an interview on 1/29/25, at 11:23 a.m. Infection Preventionist Employee E4 stated, We placed in her Contact Precautions when she had shingles. We don't write orders for isolation precautions; we update the resident care plans to reflect any isolation precautions. During an interview on 1/29/25, at 12:11 p.m. Infection Preventionist Employee E4 confirmed there was no documentation in Resident R36's plan of care to reflect being placed in Contact Precautions for shingles and there was no documentation to implement EBP related to the resident's wounds and indwelling medical devices. During an interview on 1/29/25, at 12:11 p.m. Infection Preventionist Employee E4 confirmed that the facility failed to implement transmission-based precautions as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of clinical record review and staff interviews it was determined that the facility failed to follow physician orders for one of seven residents (Resident R23) and failed to provide appropriate treatment and care by failing to ensure timely notification to the physician of significant weight loss and failing to implement physician orders in a timely manner for one of seven residents (Resident R36). Findings include: Review of facility policy Physician Notification dated 5/23/24, indicated attending physicians will be notified of changes in resident conditions, incidents involving resident injury, or have the potential for needing physician interventions. Review of facility policy Weight Loss Prevention dated 5/23/24, indicated to update MD (physician) and obtain orders as needed. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE S483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record indicated that Resident R23 was admitted to the facility on [DATE], with diagnosis that included congestive heart failure, cerebral palsy (group of disorders that affect movement, muscle tone, and posture due to damage or abnormal development of the brain during or shortly after birth) and asthma. Review of Resident R23's physician orders dated 7/19/24, indicated that Resident R23 was ordered Empagliflozin Oral Tablet 10 MG (milligrams) 1 tablet by mouth. Review of Resident R23's MAR (medical administration record), the following was not administered: Empagliflozin 1/20/25, 1/19/25, 12/21/24, 12/7/24, 12/6/24. Review of Resident R23's clinical nurse notes indicated medications awaiting med to be delivered from pharmacy and resident R23 did not receive on 1/20/25, 1/19/25, 12/21/24, 12/7/24, 12/6/24. During an interview on 1/30/25, at 11:00 a.m. the Director of Nursing confirmed that resident did not receive the medication on the above days and the physician was not notified. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record indicated that the physician was not made aware of Resident R36's 9.12% weight loss until 11/1/24. Review of Daily Progress note dated 11/1/24, indicated Resident R36 experiences frequent increased stomach residual necessitating need to hold/stop feeding and had significant weight loss noted in 30-day period 119.5 to 108.6. The physician documented, Weight loss noted - needs full nutritional assessment and perhaps a change in substrate (tube feeding formula). Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of the above order indicates this is a decrease in amount of formula to be administered. Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. During an interview on 1/29/25, at 1:45 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 stated, I caught the weight loss in October when I was filling out that portion of the MDS. Usually, the Registered Dietitian would be who catches weight loss and makes recommendations. I round with the physician and made him aware of the weight loss on November 1st and the physician gave a verbal order to change her tube feeding formula. It wasn't changed to a different formula until December 12th because we had to use up her current tube feeding supply, we can't return anything. During an interview on 1/29/25, at 1:45 p.m. LPNAC Employee E4 confirmed that the facility failed to provide appropriate treatment and care by failing to ensure timely notification to the physician of significant weight loss and failing to implement physician orders in a timely manner as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services for one of four residents (Resident R36). Findings include: Review of facility policy Enteral Therapy dated 5/23/24, indicated the dietitian will assess the resident's nutritional needs and provide consultation to the MD (physician) as indicated. Review of facility policy Weight Loss Prevention dated 5/23/24, indicated Dietitian or Dietitian Tech to evaluate and make recommendations as indicated. Update MD (physician) and obtain orders as needed. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE S483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45 cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of the above order indicates this is a decrease in amount of formula to be administered. Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of a Weight Change Note dated 8/13/24, completed by Registered Dietitian (RD) Employee E1 stated, Review of monthly weight status. Per weight 8/1 120# (pounds), resident with trigger for significant weight loss for 6 months (133.5#, -10.1%). Weight stable past 3 months 116-121#. Continue current TF (tube feeding) as ordered/resident tolerates. Continue to monitor weight status for significant change. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in September 2024, October 2024, November 2024, and December 2024. The review of the clinical record failed to reveal any documentation regarding the above weight changes or any nutritional recommendations. During an interview on 1/29/25, at 9:32 a.m. RD Employee E1 stated, I was not employed at the facility between 8/20/24 and 11/6/24. I can't speak exactly to Resident R36's weight loss in September. I was notified through email communication at the beginning of November. My recommendation was to increase her tube feeding rate, but her husband dictates most of her care and had no desire to increase the tube feeding rate. When asked if it is documented in Resident R36's clinical record that her husband refused to have nutritional recommendations implemented, RD Employee E1 stated, Nobody would dare put that in. Review of Resident R36's clinical record indicated that the physician was not made aware of Resident R36's 9.12% weight loss until 11/1/24. Review of Daily Progress note dated 11/1/24, indicated Resident R36 experiences frequent increased stomach residual necessitating need to hold/stop feeding and had significant weight loss noted in 30-day period 119.5 to 108.6. The physician documented, Weight loss noted - needs full nutritional assessment and perhaps a change in substrate (tube feeding formula). During an interview on 1/29/25, at 1:45 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 stated, I caught the weight loss in October when I was filling out that portion of the MDS. Usually, the Registered Dietitian would be who catches weight loss and makes recommendations. I round with the physician and made him aware of the weight loss on November 1st and the physician gave a verbal order to change her tube feeding formula. It wasn't changed to a different formula until December 12th because we had to use up her current tube feeding supply, we can't return anything. During an interview on 1/29/25, at 1:45 p.m. LPNAC Employee E4 confirmed that the facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services as required. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1) Nursing services.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm for one of two residents when the resident was not provided appropriate treatment and services to maintain bowel function and prevent actual harm of a fecal impaction. (Resident R86). Findings include: The facility's Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property policy dated 12/31/18, indicated that the facility prohibits and prevents abuse and neglect, with physical neglect being defined as the deprivation of goods and services necessary to maintain physical or mental health. A review of the clinical record revealed that Resident R86 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/19, included [DIAGNOSES REDACTED]. Section H Bladder and Bowel, Question H0400 Bowel Incontinence indicated that Resident R86 was always incontinent of bowel. A review of the Plan of Care dated 1/17/18, indicated that Resident R86 required assistance with toilet use and had an ongoing problem with constipation. Interventions included utilizing the bowel protocol, monitoring opioid administration for side effects of constipation, and reporting abnormal findings. A review of the Bowel and Bladder Elimination report, dated 3/1/19, through 3/31/19, did not include a bowel movement from 3/7/19, through 3/25/19 for Resident R86. A review of the recapitulation physician orders [REDACTED]. The (MONTH) 2019, Medication Administration Record [REDACTED] The [MEDICATION NAME] (ordered every 8 hours for severe pain) was administered ten times between 3/7/19, and 3/25/19. The [MEDICATION NAME] suppository (ordered every 24 hours for constipation) was not administered between 3/7/19, and 3/25/19. The Fleet enema (ordered every 24 hours for constipation) was not administered between 3/7/19, and 3/24/19, with one administration on 3/25/19, prior to admission to the hospital later that day. The Milk of Magnesia (ordered every 24 hours for constipation) was administered on 3/13/19, and 3/24/19, both times was noted to be ineffective. Review of nursing progress notes dated 3/25/19, at 10:41 a.m. indicated that Resident R86 complained of constipation, had a distended abdomen, and hypoactive (less than normally active) bowel sounds. A physician's progress note dated 3/25/19, indicated that Resident R86 had feeble bowel sounds and to send Resident R86 to the emergency room . Review of the hospital Discharge Clinical Summary dated 3/27/19, indicated that Resident R86 was admitted to the hospital on [DATE], with a fecal impaction (blockage of intestines related to severe constipation), constipation due to opioid therapy, and colonic inertia (a motility disorder that affects the large intestine (colon) and results in the abnormal passage of stool). During an interview on 4/26/19, at 10:00 a.m. Registered Nurse Employee E4 confirmed that the facility failed to administer medications to prevent constipation resulting in a fecal impaction, resulting in harm for Resident R86. The facility failed to make certain that Resident R86 was protected from neglect resulting in actual harm by not providing appropriate treatment and services to maintain bowel function and prevent hospitalization from a fecal impaction. 42 CFR 483.12(a)(1) Free From Abuse and Neglect 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 4/24/17 and 3/16/18 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a) Resident Rights Previously cited 4/24/17 28 Pa. Code 201.29(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c) Resident Care Policies. Previously cited 3/16/18 28 Pa. Code 211.10(c)(d) Resident Care Policies. Previously cited 4/24/17 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/24/17 and 3/16/18 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/24/17.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm for one of two residents when the resident was not provided appropriate treatment and services to maintain bowel function and prevent actual harm of a fecal impaction. (Resident R86). Findings include: A review of the clinical record revealed that Resident R86 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/19, included [DIAGNOSES REDACTED]. Section H Bladder and Bowel, Question H0400 Bowel Incontinence indicated that Resident R86 was always incontinent of bowel. A review of the Plan of Care dated 1/17/18, indicated that Resident R86 required assistance with toilet use and had an ongoing problem with constipation. Interventions included utilizing the bowel protocol, monitoring opioid administration for side effects of constipation, and reporting abnormal findings. A review of the Bowel and Bladder Elimination report, dated 3/1/19, through 3/31/19, did not include a bowel movement from 3/7/19, through 3/25/19 for Resident R86. A review of the recapitulation physician orders [REDACTED]. The (MONTH) 2019, Medication Administration Record [REDACTED] The [MEDICATION NAME] (ordered every 8 hours for severe pain) was administered ten times between 3/7/19, and 3/25/19. The [MEDICATION NAME] suppository (ordered every 24 hours for constipation) was not administered between 3/7/19, and 3/25/19. The Fleet enema (ordered every 24 hours for constipation) was not administered between 3/7/19, and 3/24/19, with one administration on 3/25/19, prior to admission to the hospital later that day. The Milk of Magnesia (ordered every 24 hours for constipation) was administered on 3/13/19, and 3/24/19, both times was noted to be ineffective. Review of nursing progress notes dated 3/25/19, at 10:41 a.m. indicated that Resident R86 complained of constipation, had a distended abdomen, and hypoactive (less than normally active) bowel sounds. A physician's progress note dated 3/25/19, indicated that Resident R86 had feeble bowel sounds and to send Resident R86 to the emergency room . Review of the hospital Discharge Clinical Summary dated 3/27/19, indicated that Resident R86 was admitted to the hospital on [DATE], with a fecal impaction (blockage of intestines related to severe constipation), constipation due to opioid therapy, and colonic inertia (a motility disorder that affects the large intestine (colon) and results in the abnormal passage of stool). During an interview on 4/26/19, at 10:00 a.m. Registered Nurse Employee E4 confirmed that the facility failed to administer medications to prevent constipation resulting in a fecal impaction, resulting in harm for Resident R86. 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 4/24/17 and 3/16/18. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a) Resident Rights Previously cited 4/24/17 28 Pa. Code 201.29(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c) Resident Care Policies. Previously cited 3/16/18. 28 Pa. Code 211.10(d) Resident Care Policies. Previously cited 4/24/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/24/17 and 3/16/18. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/24/17.