Every finding on record at St Martha Center for Rehabilitation & Healthcare

Based on review of facility's policy, clinical records review and staff interviews, it was determined that the facility failed to comprehensively and accurately assess pain and provide pain management for one of two residents reviewed (Resident 1). Findings:A review of the facility's policy titled Pain Management, revised date May 2024, revealed Procedure in recognizing pain: Observe the resident during rest and movement for physiologic and behavioral (nonverbal) signs of pain. Evaluating pain: During the pain evaluation gather the following information; characteristic of pain (1) Intensity of pain (as measured on a standard pain scale) (2) description of pain (3) pattern of pain (4) location of pain and (5) frequency, timing and duration of pain. The same policy revealed Implement the medication regimen as ordered, documenting the results of the intervention.A review of Resident 1's diagnosis list includes Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain), Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Seizure Disorder (neurological conditions characterized by recurring unprovoked seizures) and Osteoporosis (A chronic bone disease that causes bones to become porous, brittle, and highly susceptible to fractures from minor falls or daily activities.A review of Resident 1's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated May 11, 2026, revealed resident had severe cognitive impairment and was dependent on all ADL's (activities of daily living).The facility utilizes PAINAD (Pain Assessment in Advanced Dementia- an observation tool used by healthcare providers and caregivers to evaluate pain levels in patients with advanced dementia or severe cognitive impairments who cannot verbally communicate their pain) pain assessment tool. 0 is no pain, 1 to 3 - mild pain, 4-6 - moderate pain, and 7-10 - severe pain.A review of Resident 1's nursing progress notes documented by the unit manager, licensed nurse Employee E3 dated June 9, 2026, at 2:24 p.m., revealed Received in report this resident had left hip pain, resident does flinch when I touch left knee, [they] has slight edema to left knee it is not red, no discharge, no odor, clean, dry and intact. [They] had Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness or partial loss of movement on one entire side of the body), notified MD (physician). The pain assessment conducted by Employee E3 did not indicate intensity/scale of the pain.An interview with Employee E3 was conducted on June 29, 2026, at 10:45 a.m. Employee E3 reported that on June 9, 2026, at 10:30 a.m., they checked Resident 1 who was already in the wheelchair. Employee E3 reported that the residents' left hip was ok but flinched when knee was touched. Employee E3 further reported that the knee was swollen. The physician was notified and ordered ace wrap to the left leg and to elevate the leg. When asked if pain medication was administered, Employee E3 responded I told the nurse of the pain and [they] would have given the medication. Employee E3 was unable to say who was the nurse they talked to.A review of Resident 1's physician's order revealed resident had an existing (ordered on February 1, 2026) order for Tramadol (A medication used to treat moderate to moderately severe pain) HCL 50 mg give 1 tablet by mouth every six hours as needed for pain.A review of Resident 1 June 2026, Medication Administration Record (MAR) revealed Resident 1 was not administered with as needed Tramadol for the left leg pain on June 9, 2026. A review of Resident 1's June 2026, MAR revealed resident was administered with as-needed Tramadol for a pain level of 3 (mild pain) on June 10, 2026, at 10:14 a.m. The pain assessment did not indicate the pain location.An interview with licensed nurse Employee E5 was conducted on June 29, 2026, at 12:30 p.m. Employee E5 reported that in the morning of June 10, 2026, Resident 1's companion approached them and reported that the resident was in pain when they moved and repositioned the resident. Employee E5 reported I came to check (the resident) and gave [them] the Tramadol. Employee E5 reported that the resident did not have pain, but they also confirmed that they did not touch/move the resident during the assessment, despite the companion's report that the pain was observed when the resident was moved and repositioned. The above findings were conveyed with the Director of Nursing and Nursing Home Administrator on June 29, 2026, at 1:00 p.m.The facility failed to ensure Resident 1's pain was comprehensively and accurately assessed, and managed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on a review of the facility's policy, a clinical records review, observations, and staff interviews, it was determined that the facility failed to comprehensively investigate an injury of unknown origin for one of the two residents reviewed (Resident 1). Findings: A review of the facility's policy titled Abuse Prevention/Reporting, revised on February 25, 2025, revealed that procedures have been developed and implemented to properly screen, report, protect, investigate, and correct issues relating to abuse. Staff are trained to determine types of abuse, stress management tips, and recognition of signs and symptoms of abuse, which may include, but are not limited to, the following: bruises, skin tears, welts, etc., of unknown origin, unexplained injuries. The same policy revealed: The following is a list of methods to be used to conduct the investigation: Review of records; Observe and interview residents, staff members, accused personnel, witnesses, family members, and visitors; Compile written documentation that includes signed witness statements. A review of Resident 1's diagnosis list includes Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain), Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Seizure Disorder (neurological conditions characterized by recurring unprovoked seizures) and Osteoporosis (A chronic bone disease that causes bones to become porous, brittle, and highly susceptible to fractures from minor falls or daily activities). A review of Resident 1's quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated May 11, 2026, revealed the resident had severe cognitive impairment and was dependent on all ADL's (activities of daily living). A review of Resident 1's nursing progress notes documented by the unit manager, licensed nurse Employee E3 dated June 9, 2026, at 2:24 p.m., revealed Received in report this resident had left hip pain, resident does flinch when I touch left knee (Resident 1) has slight edema (swelling) to left knee it is not red, no discharge, no odor, clean, dry and intact. (Resident 1) had Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness or partial loss of movement on one entire side of the body), notified MD (physician). The physician ordered ace wrap for the left knee. A review of Resident 1's nursing progress notes dated June 11, 2026, at 9:00 a.m., revealed Resident medicated with Tramadol (A medication used to treat moderate to moderately severe pain) this shift due to facial grimace and moan during transfer and reposition. Misaligned leg noted after informed by companion. A review of Resident 1's nursing progress notes dated June 11, 2026, at 9:10 a.m., revealed: Resident continues to have decreased ROM (range of motion), pain to left LE (lower extremity) call to MD (physician), new order for left hip and knee X-ray stat (immediately). RP (responsible party) is aware. A review of Resident 1's nursing progress notes dated June 11, 2026, at 1:11 p.m., revealed Xray of left knee total knee prosthesis with acute displaced angulated supra condylar fracture abutting the femoral portion of the hardware (is a complex injury where the femur breaks above the condyles, with significant displacement and angulation), Osteoporosis suprapatellar effusion and diffuse STS (refers to fluid accumulation in the suprapatellar bursa above the kneecap, often due to trauma, inflammation, infection, or degenerative joint disease). The physician was notified and ordered transfer to the hospital for evaluation. A review of Resident 1's nursing progress notes dated June 11, 2026, at 9:20 p.m., revealed the resident was admitted to the hospital due to a left knee fracture. A review of the facility's documentation, Incident Report, completed by Employee E3 on June 11, 2026, at 1:00 p.m., revealed the resident's left knee was slightly swollen and tender to the touch. The same report revealed the resident did not have any injuries. The physician and responsible party were notified. An order from the physician to apply ace wrap (to the left knee) was followed. On June 11, 2026, the resident had increased pain and edema to the left knee; the physician was notified and ordered an X-ray. Further review of the report revealed, An investigation was initiated, and staff was interviewed. No concerns noted. [The resident] did not have any falls or injuries, and no bruising was noted. An interview with licensed nurse Employee E4 was conducted on June 29, 2026, at 11:30 a.m. Employee E4 reported that they were Resident 1's full-time nurse. They reported that Resident 1 does not talk and was dependent on all ADL's (Activities of Daily Living). Employee E4 reported that Resident 1 had a companion that stayed with the residents from Monday until Friday, morning until after lunch. Employee E4 reported that on the morning of June 10, 2026, the companion informed them that Resident 1 had pain when moved and repositioned. Employee E4 reported that they visually checked the resident and did not observe signs of pain; the resident was medicated with Tramadol. An observation conducted on June 29, 2026, revealed Resident 1 was roommate with Resident 2. A review of Resident 2's quarterly MDS dated [DATE], revealed that the resident was cognitively intact. A review of the facility's documentation and investigation of Resident 1's left knee fracture of unknown origin revealed that eight statements from the staff (assigned to the resident) did not have their signatures. Further review revealed the resident's roommate, who was alert and oriented was not interviewed. Furthermore, the resident's companion who was with the resident five times a week every morning and the one who reported the pain to Employee E4 on June 10, 2026, was not interviewed. The above findings were conveyed to the Director of Nursing and the Nursing Home Administrator on June 29, 2026, at 1:00 p.m. The NHA confirmed that Resident1's roommate and companion should have been interviewed. The facility failed to ensure Resident 1's left knee fracture of unknown origin was comprehensively investigated. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding oxygen and catheter care for 1 of 8 resident's reviewed (Resident 10).Findings include: Review of Resident 10's face sheet revealed medical diagnoses that include Obstructive and Reflex Uropathy (blockage in urinary tract), Urine Retention, Atrial Fibrillation (irregular often very rapid heart rhythm). Review of Resident 10's physician orders revealed orders dated September 5, 2025, to provide foley catheter care every shift. Review of Resident 10's December 2025, Medication Administration Report (MAR), revealed orders for foley catheter care every shift were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025, day shift, December 23, 2025, evening shift, December 24, 2025, evening shift, December 25, 2025, day and evening shift, December 26, 2025, evening shift, December 27, 2025, evening shift, December 28, 2025, day shift, and December 30, 2025 evening shift. Review of Resident 10's January 2026, MAR revealed orders for foley care every shift were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Review of Resident 10's physician orders revealed orders dated October 30, 2025, for oxygen at 2 liters via nasal cannula continuously every shift for shortness of breath. Review of Resident 10's December 2025, MAR revealed orders for oxygen at 2 liters via nasal cannula continuously every shift for shortness of breath were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025, day shift, December 23, 2025, evening shift, December 24, 2025, evening shift, December 25, 2025, day and evening shift, December 26, 2025, evening shift, December 27, 2025, evening shift, December 28, 2025, day shift, and December 30, 2025 evening shift. Review of Resident 10's January 2026, MAR revealed orders for oxygen at 2 liters via nasal cannula continuously every shift were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Review of Resident 10's physician orders revealed orders dated September 4, 2025, to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath. Review of Resident 10's December 2025, MAR revealed orders to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath were not followed on December 2, 2025, day and evening shift, December 4, 2025, day shift, December 5, 2025, day shift, December 7, 2025, day shift, December 8, 2025, evening shift, December 9. 2025, day shift, December 12, 2025, day and evening shift, December 13, 2025, day shift, December 15, 2025, evening shift, December 20, 2025, evening shift, December 21, 2025,evening shift, December 22, 2025, day shift, December 23, 2025, evening shift, December 24, 2025, evening shift, December 25, 2025, day and evening shift, December 26, 2025, evening shift, December 27, 2025, evening shift, December 28, 2025, day shift, and December 30, 2025 evening shift. Review of Resident 10's January 2026, MAR revealed orders to keep head of bed elevated to prevent shortness of breath while lying flat every shift for shortness of breath were not followed on January 2, 2025, day and evening shift, January 4, 2025, day and evening shift, and January 5, 2025, evening shift. Interview conducted with Director of Nursing (DON) on January 8, 2026, at 10:05a.m. when the above information was presented the DON confirmed the orders were not followed. 28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of facility policy, observations, clinical records and staff interviews, it was determined that the facility failed to follow physician orders for two of 22 residents reviewed (Resident 86 and 164). Finding include: A review of the facility's policy regarding Enteral Nutrition, dated March 2020, revealed adequate nutritional support through enteral feeding will be provided to residents as ordered. A review of Resident 86's clinical records revealed medical diagnoses that include Dysphagia following other Cerebrovascular Disease (swallowing disorder that occurs after a stroke or other neurological disease), Muscle Wasting and Atrophy (loss of muscle mass), and Severe Protein-Calorie Malnutrition (inadequate protein or calories in diet). Review of Resident 86's clinical records revealed a physician order dated January 9,2025, for Jevity 1.5 at 40ml/ per hour x20 hours via Kangaroo pump (pump that delivers nutrition through a tube inserted in the stomach or intestine that's programmed with desired feed rate and volume), total volume 800ml per day or until infused. Down at 11am, up at 3pm. This provides 1200 kcal, 51g protein and 608ml free water every shift for Peg-Tube. Observations of Resident 86's Kangaroo pump on February 18, 2025, at 9:30 a.m., revealed the pump was already disconnected from the resident and turned off. Observations of Resident 86's Kangaroo pump on February 19, 2025, at 9:40 a.m., revealed the pump was already disconnected from the resident and turned off. A review of Resident 86's February Medication Administration Record (MAR) revealed the resident received the following amounts of Jevity daily: February 1-2, 300ml evening, 0ml night, 160ml day for a total of 460ml February 2-3 320ml evening, 230ml night, 160ml morning for a total of 480 ml February 3-4 320ml evening, 230ml night, 160ml morning for a total of 780ml February 4-5 250ml evening, 0ml night, 160ml morning for a total of 420 ml February 5-6 320ml evening, 40ml night, 160ml morning for a total of 520ml February 6-7 300ml evening, 240ml night, 160ml morning for a total of 700ml February 7-8 240ml evening, 230ml night, 240ml day for a total of 710ml February 8-9 240ml evening, 240ml night, 0ml day for a total of 480ml February 9-10 300ml evening, 300ml night, 160ml day for a total of 760ml February 10-11 0ml evening, 240ml night, 160ml day for a total of 400ml February 11-12 300ml evening, 240ml night, 160ml day for a total of 700ml February 12-13 300ml evening, 240ml night 160ml day for a total of 700ml February 13-14 300ml evening, 230ml night, 0ml day for a total of 530ml February 14-15 0ml evening, 230ml night, 160ml day for a total of 390ml February 15-16 320ml evening, 230ml night, 160ml day for a total of 710ml February 16-17 150ml evening, 90ml night, 0ml day for a total of 240ml February 17-18 280ml evening, 230ml night, 160ml day for a total of 510ml February 18-19 200ml evening, 245ml night, 160ml day for a total of 605ml February 19-20m 300ml evening, 240ml night 160ml day for a total of 700ml Review of Resident 86's February 2025 MAR failed to reveal any day that the resident received the prescribed amount of tube feed. Interview conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on February 20, 2025, at 12:07 p.m., when the above information was presented, the ADON stated that the Kangaroo pump shuts down when the total 800ml is infused. The ADON stated the pump clears itself when it is shut off and there was no way to see a 24-hour look-back of total amounts dispensed for the pump. The DON confirmed that the amounts documented on the resident's MAR should equal the total amount prescribed in the physician orders. The DON confirmed the amounts on the resident's February MAR did not match the physician orders. A review of Resident 164's diagnosis list includes Type II Diabetes Mellitus (A chronic disease where the body does not use insulin properly or does not produce enough of it, causing high blood sugar levels). A review of the physician's order dated February 1, 2025, revealed an order for Insulin Aspart Injection Solution 100 ml/unit (fast-acting insulin) Inject 12 units subcutaneously (Injection is given in the fatty tissues, just under the skin) every six hours-injection to be given at 12:00 a.m. midnight, 6:00 a.m., 12 noon, and 6:00 p.m. A review of Resident 164's February 2025, Medication Administration Record revealed that from February 1, 2025, until February 18, 2025, Insulin Aspart was not administered to the resident seven times on the following dates: February 4, 2025, at 6:00 p.m.; February 5, 2025, at noon; February 7, 2025, at midnight; February 11, 2025, at 6:00 p.m.; February 14, 2025, at 6:00 p.m.; February 15, 2025, at 12:00 a.m., and 6:00 a.m. MAR review revealed Aspart Insulin 12 units were not administered on February 4, at 6:00 p.m., and February 5, at 12 noon. The MAR was coded with 9 which indicated BS (blood sugar) within limit coverage. MAR review revealed Aspart Insulin 12 units were not administered on February 7, 11, 14, and 15, at the times listed above. The MAR was coded with a 5 which indicated Hold/see nurses' notes A review of the progress notes dated February 7, 2025, at 3:23 a.m., revealed BS was 97 mg/dl. A review of the progress notes dated February 11, 2025, at 6:25 p.m., revealed Aspart Insulin 12 units was held for BS of 127 mg/dl. A review of the progress notes dated February 14, 2025, at 5:41 p.m., revealed Aspart Insulin 12 units was held for BS of 97 mg/dl. A review of the progress notes dated February 15, 2025, at 12:18 a.m., revealed BS was 102 mg/dl. A review of the progress notes dated February 15, 2025, at 5:20 a.m., revealed BS was 110 mg/dl. Clinical records review failed to reveal that the physician was notified that Aspart Insulin 12 units was not administered to Resident 164 on the above dates/time. The above was confirmed with the Director of Nursing on February 21, 2025, at 1:00 p.m. The facility failed to ensure Resident 164's physician order for Insulin was followed by holding insulin despite there being no paramters for the administration of insulin. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 1/12/24

Based on clinical records review and staff interview, it was determined that the facility failed to ensure appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two of five residents reviewed (Residents 3 and 22). Findings include: A review of Resident 3's physician's order dated May 24, 2024, revealed an order for Ativan (anti-anxiety medication) gel 1mg/ml applied to the base of the neck topically two times a day for Anxiety. On September 24, 2024, an order for Ativan gel 1mg/ml applied to the neck every eight hours as needed for anxiety was ordered aside from the routine Ativan gel. A review of the November 2024, Medication Administration Record revealed that from November 1, 2024, until November 30, 2024, as needed Ativan gel was administered to Resident 3 seven times with no appropriate indication and was administered five times without attempting a non-pharmacological intervention. A review of Resident 22's physician's order dated January 16, 2025, revealed an order for Clonazepam 0.5 mg (anti-anxiety medication) every 12 hours as needed for Anxiety. A review of the January 2025, MAR revealed that from January 17, 2025, until January 31, 2025, Resident 22 was administered with as-needed Clonazepam nine times without appropriate indication. The MAR also revealed that non-pharmacological interventions were not attempted before administering the as-needed Clonazepam nine times. The above was confirmed with the Director of Nursing on February 21, 2025, at 12:07 p.m. The facility failed to ensure Resident 3 and 22 were administered with as-needed anti-anxiety medication with appropriate indication and attempted non-pharmacological interventions prior to the adminstration of the as needed psycotropic medication. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 1/12/24

Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to obtain weights to maintain residents' nutritional status for four of 14 residents reviewed. (Residents 26, 74, 109, and 113) Findings Include: Review of facility policy and procedure titled Resident Weights, revised May 2022, revealed the nursing staff will measure residents' weights during the admission process which can take up to 24 to 48 hours from admitted . If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each resident electronic medical record. Any weight change of 5% or more since the last weight assessment will be retaken. If the weight is verified, nursing will notify the Dietitian. Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral Vascular Accident (CVA- interruption in the flow of blood to cells in the brain). Clinical records review revealed Resident 26 was receiving feeding through a Gastrostomy Tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) due to Dysphagia (Difficulty swallowing). Review of Resident 26's clinical records revealed resident's admission weight was taken on November 23, 2023, which was 156 pounds. Records revealed resident was sent to the hospital on the same day for respiratory failure. Review of Resident 26's clinical records review revealed resident was readmitted to the facility on [DATE]. The records failed to reveal that a readmission weight was obtained within the first 24-48 hours after readmission. Review of Resident 26's hospital records dated December 18, 2023, revealed resident's weight was 154 pounds. Review of Resident 26's weight and vitals revealed a weight of 145.4 pounds taken on December 27, 2023, seven days after the resident was readmitted from the hospital. The resident had a 5.52% weight loss from December 18, 2023, until December 27, 2023. Review of Resident 26's clinical record revealed dietitian's progress notes dated December 28, 2023, at 9:48 a.m., revealed resident was triggered for unplanned/unfavorable weight loss, re-weight requested. Review of Resident 26's clinical record revealed resident's re-weight was not conducted until January 1, 2024, (145.4 lbs.) five days after a significant weight loss was identified. Interview was conducted with the DON on January 12, 2024. The DON reported that re-weights are done within 24 hours. The DON reported that Resident 26's readmission weight was not done until seven days later due to the weight lift not working. Review of Resident 74's weights revealed a weight on September 1, 2023 of 105.2 pounds and a weight on December 1, 2023 of 89.4 pounds, a decrease of 15.02% over three months. Further review of Resident 74's weights revealed there was no weight obtained after December 1, 2023. Review of Resident 74's Progress Notes revealed a nursing entry dated December 28, 2023 at 2:01 p.m. revealed the resident had returned from the hospital and now had a feeding tube. Review of resident 74's weights revealed there was no documented weight for Resident 74 when readmitted to the facility on [DATE] and resident 74 had not been weighed since December 1, 2023. Review of Resident 74's Nutritional readmission assessment dated [DATE] revealed Resident 74 was readmitted from the hospital on December 28, 2023 with a new PEG tube (feeding tube) placement on December 26, 2023. Resident 74's weight was documented as 89 pounds and it was noted that the re-admission weight was pending. Interview with Licensed Dietitian E3 on January 11, 2023 at 1:00 p.m. confirmed there was no readmission weight completed for Resident 74 on December 28, 2024 and there had been no weights completed for that resident at the time of the interview since December 1, 2023. Review of Resident 109 weights revealed a weight on December 1, 2023 of 138 pound. There were no weights after this date documented in resident 109 clinical record. Review of Resident 109 Progress notes revealed a Dietary Weight Change Note on October 6, 2023 noting Resident 109 had a weight on September 11, 2023 of 159.2 pounds and a weight on October 3, 2023 of 150 pounds an unplanned and unfavorable weight loss of 9.2 pound or 5.8%. Weekly weights for four weeks were recommended related to the resident's weight loss. Review of Resident 109 weights revealed a weight on October 11, 2023 of 149.4 pounds and a weight on November 3, 2023 of 134 pounds. Interview with Licensed Dietitian E3 on January 11, 2023 at 1:00 p.m. confirmed the weekly weights that were recommended on October 3, 2023 were not completed and the resident had no documented weight since December 1, 2023. Review of Resident 113's weights and vitals revealed a weight of 149.3 pounds on December 20, 2023. On January 1, 2024, the resident's weight was 124 pounds, a 16.95% weight loss in 12 days. Review of Resident 113's clinical record revealed dietitian progress notes dated January 3, 2024, at 11:06 a.m., revealed resident was triggered for significant unplanned/unfavorable weight loss. Re-weight requested and will follow up upon re-weight obtainment. Interview conducted with the dietitian on January 11, 2024, revealed Resident 113's re-weight requested on January 3, 2024, was not done until January 11, 2024, after the surveyor had asked for it. The above information was conveyed with the DON on January 12, 2024. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on clinical records review and staff interview, it was determined that the facility failed to ensure physician orders regarding medications were followed for two of the 24 residents reviewed (Residents 26 and 97). Findings include: Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain). Review of Resident 26's clinical records revealed Resident 26 had a Gastrostomy Tube (GT- A tube inserted through the belly that brings nutrition directly to the stomach) due to Dysphagia (Difficulty swallowing). Review of Resident 26's physician order (POS) revealed an order initiated on December 20, 2023, for Insulin Gargline (Long-acting insulin) Subcutaneous Pen-Injector 100 unit/ml Inject 24 units subcutaneously at bedtime. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed resident was not administered with the ordered Insulin Gargline on December 20, 21, 22, 26, and 29, 2023. Interview with the Director of Nursing (DON) was conducted on January 12. 2024. The DON indicated the nurse did not administer Resident 26's ordered Insulin Gargline on the above dates because the resident's tube feeding was held due to abdominal discomfort, thus the nurse held the ordered insulin as per nursing judgment. The Director of Nursing confirmed the physician was not notified of the missed Insulin Gargline on the above-mentioned dates. The facility failed to ensure Resident 26 was administered the ordered Insulin Gargline daily at bedtime. Review of Resident 97's POS dated December 7, 2023, revealed an order for Midodrine HCL (medication used to treat low blood pressure) oral tablet 2.5 mg given one tablet by mouth three times a day. Hold for systolic >140. Review of Resident 97's December 2023 MAR (Medication Administration Record) revealed from December 7, 2023, until December 31, 2023, Resident 97 was administered the Midodrine medication outside of the ordered blood pressure parameter, a total of six times. Review of Resident 97's January 2024 MAR revealed that from January 1, 2024, until January 11, 2024, Resident 97 was administered seven times with Midodrine medication outside of the ordered blood pressure parameter. The above information was conveyed to the Director of Nursing on January 12, 2024, at 11:00 a.m. The facility failed to ensure Resident 102's physician's order for blood pressure parameters before administering Midodrine medication was followed. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for a planned discharge for one of one residents reviewed. (Resident 112) Findings Include: Review of Resident 112's Physician Orders revealed an order dated January 8, 2024 for the resident to be discharged to a group home on January 8, 2024. Review of Resident 112's entire clinical record revealed there was no discharge summary completed upon discharge. Interview with the Director of Nursing on January 12, 2023 at 11:30 a.m. confirmed there was no discharge summary completed upon the discharge of Resident 112. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on clinical records review, resident and staff interview, it was determined that the facility failed to implement a comprehensive care plan intervention to prevent alteration in nutrition and hydration for one of eight residents reviewed (Resident R14). Findings include: Review of R14's records revealed a care plan dated May 12, 2020, documenting the resident has potential for self-care deficit. Interventions included resident requires eating assist x one person. Further review of R14's records revealed a care plan dated May 12, 2020, with a revision date of November 17, 2023, documenting R14 has the potential for alteration in nutrition and hydration. Intervention dated March 29, 2022, documented the need for staff to assess R14's ability to prepare food/fluids and feed self. Interventions also included the need to offer the resident assistance as needed. An intervention dated September 6, 2023, documented the need for adaptive equipment: lipped plate with meals. Observation of R14 on January 10, 2024, at 09:02 AM, revealed the resident having difficulty eating. The resident had food on her clothes and face. The resident was observed trying to grab a pastry from the table. The pastry was sitting on a tissue, no plate was observed on the table. The resident was able to grab the pastry, but not able to remove the tissue. The resident became frustrated, put the pastry back on the table and didn't attempt to eat it again. Observation of R14 on January 11, 2024, at 09:15 AM, revealed resident in the dining room with a plate on her lap attempting to eat breakfast. The resident was observed with food on her clothing and face. The resident did not have a lipped plate, or a staff person to assist with eating as documented in her care plan. Interview on January 11, 2024, at 09:33 AM with E#3, confirmed that R14 was care planned for a lipped plate and one person assist with eating. Interview on January 12, 2024, at 11:32 AM with DON, confirmed that R14 was care planned for a lipped plate and one person assist with eating. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/18/21 28 Pa Code 211.11(d) Resident care plan 3/26/18, 8/4/21, 9/29/21 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that laboratory test was obtained as ordered by the physician for one of the 24 residents reviewed (Resident 35). Findings include: Review of Resident 35's diagnosis list includes Heart Failure and Atrial Fibrillation (A-fib- An irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 35's clinical records review revealed resident was receiving Jantoven (Warfarin) for blood clot prevention. Review of the Physicians order dated October 23, 2023, revealed an order for PT (Prothrombin Time- a test that measures how long it takes for a clot to form in a blood sample) and INR (International Normalized Ratio- a type of calculation based on PT test results) every other day, call the physician for INR >3, INR<1.5. Review of Resident 35's clinical records revealed that INR was done on October 25, 2023, but failed to reveal that the INR test was done on October 27, 2023. Clinical records review failed to reveal that the physician was notified that the October 27, 2023, PT/ INR blood test was not done. Review of Resident 35's clinical record revealed the laboratory results reported on October 30, 2023, revealed an H (high) result of 44.1 (normal range 9.7 - 12.5 sec) and a CH (critical high) INR result was 4.2 (normal range 0.8-1.1) Review of Resident 35's clinical records, physician order dated October 30, 2023, revealed an order of Phytonadione Solution (Vitamin K- A medication used to prevent bleeding in people with blood clotting problems) 10mg/ml, Inject 5 milligram one time only for critical INR for one day. Review of Resident 35's clinical record the Medication Administration Record (MAR) revealed Resident 35 was administered with Vitamin K injection on October 30, 2023, at 5:37 p.m. due to a critical high INR result. Interview was conducted with the Director of Nursing on January 12, 2023, at 11:00 a.m., who confirmed that the PT/INR test on October 27, 2023, was not done. The DON was unable to provide a reason as to why Resident 35's PT/INR test was not done on October 27, 2023, a test that could indicate if an adjustment on the resident's medication dosage is needed. The facility failed to ensure Resident 35's PT/INR blood test was done on October 27, 2023. 42 CFR 483.50(a)(1)(i) Laboratory Services. 28 Pa. Code 211.5(f) Clinical record. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy services provided medications timely for two of the 24 residents reviewed. (Resident 26 and 102) Finding include: Review of Resident 26's clinical record revealed Resident 26 was readmitted to the facility on [DATE]. Review of Resident 26's physician order (POS) dated December 20, 2023, revealed an order for Onfi Oral Suspension (A medication used to treat seizures) 2.5 mg/ml given 3 ml every 12 hours for Seizures. The medication was scheduled for 9:00 a.m. and 9:00 p.m. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed that the Onfi medication was not administered to the resident until the morning of December 25, 2023, five days after the medication was ordered. MAR review revealed that the resident had missed a total of nine doses of the Onfi medication. Interview with the Director of Nursing was conducted on January 12, 2024. The DON reported that the medication was not administered because of the unavailability of the medication from the pharmacy. Review of Resident 102's clinical records revealed resident was readmitted to the facility on [DATE], with a diagnosis of Osteomyelitis (bone infection) of the Vertebra. Review of the POS dated November 23, 2023, revealed an order for Cefepime HCL (medication used to treat bacterial infection) injection solution, using two grams intravenously every 8 hours for infection for 39 days. Review of Resident 102's November 2023 MAR revealed that Cefepime medication was not administered to the resident until the morning of November 27, 2023, four days after the medication was ordered. Interview with the Director of Nursing was conducted on January 12, 2024. The DON reported that the medication was not administered because of the unavailability of the medication from the pharmacy. The facility failed to ensure Resident 26, and Resident 102 ordered medications were administered due to unavailable from the pharmacy. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 Pa. Code: 211.9 (a)(1) Pharmacy services.

Based on resident and staff interviews, observations, and facility documentation review it was determined the facility failed to have adequate number of dietary staff to meet the needs of the residents. Findings Include: Interviews conducted with Resident R1, R2, R3, R4, and R5 on August 29, 2023 between 9:15 and 9:50 a.m. revealed the breakfast trays are always late for the residents and arrive between 9:15 a.m. and 10:15 a.m. Observations of the breakfast tray delivery on August 29, 2023 revealed the last tray was delivered to a resident on the 600 hall at 10:10 a.m. Observation of the dining room during the breakfast meal revealed the dining room was not being used and a sign was posted to the door that it opens at 8:15 a.m. Interview with Dietary Director Employee E3 on August 29, 2023 at 10:35 a.m. revealed the kitchen was short staffed the day of the survey. The kitchen should be staffed with three staff on tray line, on staff member to pushed the completed carts to the units and one cook and one dishwasher, today the kitchen was staffed with one staff on tray line, on to push the carts and one dishwasher with another staff who came in to put the order that delivered away and the dietary director helping in the kitchen with production. The dietary director confirmed the kitchen was short of two staff members for the breakfast meal. Review of the facility assessment, last assessed on July 25, 2023 revealed the facility needs on average 5-7 staff members per meal. Further interview with the Dietary Director Employee E3 on August 29, 2023 confirmed the meal trays were late and that the dinning room was not open because there was not enough dietary staff to have breakfast served both in the dinning room and on the units. Interview with the Nursing Home Administrator and the Director of Nursing on August 29, 2023 at 11:00 a.m. confirmed there was not a sufficient number of staff in the kitchen to meet the needs of the residents resulting in breakfast being delivered late and the residents not being able to eat in the dining room if preferred. 28 Pa Code 211.6(c) Dietary services. 28 Pa. Code 201.18(b)(6) Management

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for three of nine residents reviewed (Residents R4, R5, and R6). Findings include: Review of Resident R4's physician's orders included an order for Oxycodone/APAP5/325 milligrams(mg) (Percocet - used to help relieve moderate to severe pain) one tablet every eight hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 11, 2023, at 6:45 p.m. and March 12, 2023, at 2:50 a.m.; however, the administration was not documented on the electronic Medication Administration Record (MAR). Review of Resident R5's physician's orders included an order for Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 mg one tablet every four hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 11:15 p.m., March 10, 2023, at 4:40 a.m., and March 11, 2023, at 11:45 p.m.; however, the administration was not documented on the electronic MAR. Review of Resident R6's physician's orders included an order for Oxycodone IR 5 mg one tablet every six hours as needed for severe pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 4:10 p.m. and 10:30 p.m.; however, the administration was not documented on the electronic MAR. Interview with the Director of Nursing on , April 27, 2023, at 10:45 a.m. confirmed that the medications should be documented on both the controlled substance record and the MARs, but were not documented on the MARs. 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/10/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 3/10/23

Based on a review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agencies for three of nine residents reviewed (Residents R1, R2, and Resident R3). Findings include: Review of facility policy Abuse Prevention/ Reporting revised April 2022, revealed that the facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13. Review of Resident R1's progress note of March 9, 2023, revealed that Resident R1 was admitted to the hospital. Review of Resident R1's Individual Patient Controlled Substance Administration Record revealed that one tablet of Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 milligrams (mg) was signed out on March 10, 2023, by licensed staff Employee E3. Review of Resident R2's physician's orders included an order for Tramadol (opioid used to help relieve moderate to severe pain) 50 mg one tablet twice a day. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. and 6 p.m. Review of Resident R2's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 12, 2023 at 3:00 a.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Tramadol at 3:00 a.m. on March 12, 2023. Review of Resident R3's physician's orders included an order for Oxycodone/APAP 5/325 mg (Percocet - used to help relieve moderate to severe pain) two tablets once daily. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. Review of Resident R3's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 10, 2023 at 1:15 a.m. and two tablets on March 11, 2023, at 11:30 p.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Oxycodone/APAP at those times. Interview with the Director of Nursing (DON) on April 27, 2023, at 10:45 a.m. revealed that the DON was notified that Employee E3 had signed out medication for Resident R1 while Resident R1 was hospitalized and that Employee E3 was not always documenting on the resident MARs. Employee E3's agency was made aware of the issues and was asked to not return to the facility. The DON confirmed that the allegation of misappropriation was not reported to the Department of Health. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 3/10/23 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa Code 211.10(a)(d) Resident Care Policies Previously cited 3/10/23

Based on a review of facility documentation, observation, and staff interview it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of two units (Garden). Findings include: Review of the facility's policy titled Meal assessments, dated November 28, 2017, revealed that foods are served at temperatures appropriate for food safety and palatability. Review of the facility's documentation, Tray Assessments revealed that the standard temperature at the point of service is 140 F min.(minimum) for starch, vegetables, and entree. Observation of the lunch meal on March 8, 2023, in the presence of the Dining Director, Employee E3 revealed that the food cart was ready at 12:04 p.m., and staff started to deliver the resident's meal to the rooms. The last resident was assisted with their meal at 12:12 p.m. A test tray was evaluated at 12:14 p.m., with Employee E3. The test tray revealed the following temperatures: Ham was 112 degrees F, cabbage was 123 F, and sweet potato is 126 F. An interview with Employee E3 on March 8, 2023, at 12:20 p.m., revealed that the expectation as per the facility's policy temperature at the point of service for hot food should not be less than 145 F. The above was conveyed to the Director of nursing on March 10, 2023, at 1:00 p.m. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services

Based on clinical record review and staff interviews it was determined that the facility did not update or revise the care plan in a timely manner for one of 32 residents reviewed (Resident 363). Findings include: Review of the clinical record of Resident 363 revealed, an admitted [DATE], with the following (but not limited to) diagnosis; Cerebral infarction (Stroke), muscle weakness, history of falls, and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of Resident 363's clinical record revealed nursing notes for September 17, 2022, the resident was transferring to the wheelchair, without assistance, and fell sideways, landing on their bottom. September 19, 2022, a nursing note stating that the resident was standing up from the wheelchair and then fell back on the floor and an adjacent chair fell on top of the resident. September 20, 2022, a nursing note states that the resident fell on the floor in the lounge striking his head and reporting pain in the left groin or hip with movement and some pain to right leg. A skin tear was noted to the left hand next to the 5th digit and was sent to the emergency room . Review of nursing note from December 26, 2022, observed resident lying on his left side on the floor matt. Resident unable to explain what happened due to cognitive disorder. A nursing note dated December 31, 2022, revealed observed resident lying next to his bed on his right side with both legs extended. A nursing note dated January 8, 2023, revealed the resident was on the floor matt located on the right side of the bed. Review of Resident 363's care plan revealed that a care plan was developed for falls on September 19, 2020. Further review of the care plan revealed that new interventions were not put into place to prevent further falls until September 26, 2022, six days after the resident returned from the emergency room and again on January 17, 2023. Interview with the Director of Nursing on March 10, 2023, at 12:45 p.m. confirmed that no interventions were added to the resident's care plan timely to prevent further falls. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician, and/or clarify physician orders regarding daily weights for edema for one resident and for insulin administration for one resident (Resident 48 and Resident 78). Findings include: Review of Resident 48's diagnosis list revealed a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to remove sugar from the blood stream). Review of Resident 48's physician orders revealed an order for Novolog Solution (medication used for diabetes management) 100 units/milliliter (ml) inject as per sliding scale 0-150 - 1 unit; 151-200 - 2 units; 201-250 - 3 units; 251-300 - 4 units; 351-400 - 5 units; 401-450 - 6 units subcutaneously (below skin) before meals and at bedtime. Review of Resident 48's December 2022 Medication Administration Record (MAR) revealed that insulin was not administered according to physician orders on the following dates: December 2 at 4:30 p.m.; December 4 at 11:00 a.m.; December 5 at 6:30 a.m.; December 6 at 6:30 a.m.; December 7 at 6:30 a.m.; December 8 at 11:00 a.m.; December 9 at 11:00 a.m.; December 10 at 8:00 p.m.; December 13 at 4:30 p.m.; December 14 at 11:00 a.m.; December 19 at 11:00 a.m.; December 20 at 6:30 a.m.; December 22 at 11:30 a.m.; December 24 at 11:00 a.m. December 26 at 8:00 p.m.; December 27 at 4:30 p.m. and December 30 at 6:30 a.m. Review of Resident 48's January 2023 MAR revealed that Resident 48's insulin was not administered according to physician orders on the following dates: January 1 at 6:30 and 11:00 a.m.; January 2 at 6:30 a.m.; January 4 at 6:30 a.m. and 11:00 a.m.; January 6 at 11:30 a.m.; January 7 at 11:00 a.m., 4:30 p.m. and 8:00 p.m.; January 10 at 6:30 a.m.; January 11 at 6:30 a.m. and 11:00 a.m.; January 12 at 11:00 a.m.; January 14 at 4:30 p.m.; January 15 at 4:30 p.m.and 8:00 p.m.; January 16 at 6:30 a.m. 11:00 a.m. and 8:00 p.m.; January 17 at 6:30 a.m.; January 29 at 4:30 p.m. and 8:00 p.m.; January 30 at 4:30 p.m.; January 31 at 6:30 a.m. and 4:30 p.m. Interview with the Director of Nursing and Nursing Home Administrator on March 9, 2023, at 1:00 p.m. confirmed that Resident 48 did not receive insulin according to Resident 48's physician orders. The facility failed to ensure Resident 48's physician's orders were followed and failed to ensure medication was administered as ordered by attending physician. Review of Resident 78's electronic clinical record revealed the following physician order Daily weights, every dayshift for edema (swelling caused by too much fluid trapped in the body's tissues) with an order date of December 28, 2022, at 9: 48 A.M. Further review of Resident 78's clinical record revealed the following dates that weights were taken, January 5, 2023, February 2, 2023, February 4, 2023. And March 7, 20233. Additional review of Resident 78's clinical record revealed that the facility failed to weigh resident R78; 69 times between December 28, 2022, and March 10, 2023. Interviews conducted with RD1 and RD2 on March 9, 2023, at approximately 11:59 A.M. confirmed the facility failed to follow resident R78's physician order for daily weights. Interview conducted with the Nursing Home Administrator on March 9, 2023, at approximately 1:15 P.M. confirmed the facility failed to follow resident R78's physician order of daily weight. The facility failed to follow physician and or clarify physician orders regarding Medication Administration. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a rationale from attending physician was provided for disagreed recommendations provided by the pharmacy consultant for one of 24 residents reviewed (Resident 54). Findings include: Review of Resident 54's diagnosis list revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Psychosis- A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality. Review of the May 2022 Medication Administration Record (MAR) revealed an order of Quetiapine Fumarate tablet (Antipsychotic medication) 25mg given 0.5 tablets by mouth related to Psychotic Disorder with Delusions. The medication was ordered on May 13, 2021. Review of the Pharmacy Consultant report dated May 30, 2022, revealed a recommendation to consider a GDR (Gradual Dose Reduction) for Quetiapine 12.5 mg, especially with a psychotic disorder. The Pharmacist also indicated in the consult the currently accepted diagnosis for antipsychotics. Further review of the report revealed that the physician responded to the pharmacy recommendation on June 14, 2022, with a note of no change. The physician did not provide a rationale for his/her response. Review of the Pharmacy Consultant report dated August 25, 2022, revealed a recommendation as follows Quetiapine with the psychotic disorder will trigger MDS (Minimum Data Set- standardized assessment tool that measures health status in long-term care residents) inappropriate use on the quality indicator report. Please review the diagnosis. The physician responded Disagree with no rationale provided. Review of the Pharmacy Consultant report dated November 13, 2022, revealed a recommendation as follows Quetiapine with the psychotic disorder will trigger MDS inappropriate use on the quality indicator report. Please review the diagnosis and usage in considering a GDR. The physician responded Disagree with no rationale provided. Interview with the Director of Nursing on March 10, 2023, at 1:00 p.m., confirmed that there was no documentation of the physician's reasons/rationale for the disagreed recommendations from the pharmacy consultant regarding a GDR and appropriate antipsychotic diagnosis. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indication provided before the administration of as-needed anti-anxiety medication for one of 22 residents reviewed (Resident 19). Findings include: Review of the facility's policy titled [CONDITION(S)] Medications, with an effective date of March 2020, revealed pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Review of Resident 19's diagnosis list revealed Anxiety disorder (significant distress or impairment in social, academic, occupational, or other important areas of functioning) and Major Depressive Disorder (persistent feeling of sadness and loss of interest in activities of daily living). Review of Resident 19's physician orders revealed an order on November 30, 2019, for [MEDICATION(S)] ([MEDICATION(S)]- medication used to treat anxiety) 0.5 mg (miligrams), one tablet two times a day. Additional review of physician orders revealed an order for [MEDICATION(S)] 0.5 mg one tablet every six hours as needed for anxiety. The order had start dates of January 17, 2022, February 17, 2022, and March 22, 2022. Review of Resident 19's February and March 2022's Medication Administration Record (MAR) revealed an order to indicate non-pharmacological intervention(s) attempted before PRN (as needed) medication. Review of Resident 19's February 2022's MAR revealed, resident was administered PRN [MEDICATION(S)] 26 times. The MAR review revealed of the 26 doses, the medication was administered six times with no appropriate indication and administered 13 times without non-pharmacological interventions provided prior to administration. Review of Resident 19's March 2022's MAR revealed that the resident was administered the PRN [MEDICATION(S)] 27 times. Additional MAR review revealed of the 27 doses, the medication was administered seven times with no appropriate indication and administered 11 times without providing non-pharmacological interventions prior to administration. The above information was conveyed to the Director of Nursing on March 31, 2022, at 10:00 a.m. The facility failed to ensure non-pharmacological interventions were provided prior to administration and appropriate indications for administering the PRN [MEDICATION(S)] for Resident 19. 28 Pa. Code: 211.12(d)(5)Nursing Services Previously cited on 8/4/21, 3/18/21 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services Previously cited on 8/4/21, 3/18/21

Based on clinical records review, resident and staff interview, it was determined that the facility failed to implement the comprehensive care plan intervention to prevent a fall for one of two residents reviewed (Resident R1). Findings include: A review of Resident R1's diagnosis list revealed Paraplegia (paralysis of the lower half of the body), and Spondylosis (degeneration of the vertebral column from any cause). A review of Resident R1's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated July 21, 2021, revealed that the resident does not ambulate, and required total assistance with two-person physical (hands on) assistance when transferring. Review of Resident R1's clinical record revealed a social service note dated March 24, 2021, at 11:45 a.m., indicating the resident had requested a care plan meeting with daughter, Ombudsman, social worker, and nursing supervisor. The following were discussed in the meeting, time of getting out of bed in the morning, catheter care, medications, and wheelchair. The note indicated that the resident feels that the chair cushion in the wheelchair slides when the resident is sitting on it. The note revealed, we (care team) suggested dycem (non-slip material used to stabilize or to hold an object in place) to be added to prevent sliding. All were in agreement with the current care plan. Review of Resident R1's current fall care plan and interventions revised on readmission to the facility on [DATE], revealed an intervention of dycem placed on w/c (wheelchair) under seat cushion to prevent the cushion from sliding. Review of Resident R1's nursing progress notes dated July 20, 2021, at 1:32 p.m., revealed that at 11:34 a.m., the resident returned from a doctor's appointment. The resident required repositioning in the wheelchair with two staff members then was to be lowered to the floor. The progress notes revealed per the resident, she/he slid off the wheelchair. An interview with Resident R1 on August 4, 2021, at 10:00 a.m., revealed that she/he had reported her/his concern to the staff regarding sliding off her/his wheelchair. Observation on August 4, 2021, at 10:30 a.m., revealed Resident R1 sited on a black thick gel cushion on the wheelchair. A quarter part of the cushion was observed already off the base of the wheelchair seat. An interview with the resident on August 4, 2021, at 10:30 a.m., revealed that she/he feels like she was sliding. Observation on August 4, 2021, at 11:00 a.m., in the presence of the licensed nurse Employee E4 revealed that there was no dycem under the resident's wheelchair seat cushion. An interview with the resident's regular morning nurse aide, Employee E5, on August 4, 2021, at 11:15 a.m., revealed that she/he does not know what is dycem. An interview with licensed nurse Employee E6 on August 4, 2021, at 2:10 p.m., indicated, Resident R1 refused to have the dycem place under her/his seat cushion on July 15, 2021, when the resident was readmitted to the facility. Review of the clinical record failed to reveal documentation that Resident R1 had refused the dycem placement under his/her chair cushion. Review of the resident's clinical record failed to reveal that the fall intervention to place dycem under the resident's seat cushion to prevent the cushion from sliding and prevent a further fall was implemented. The above information was conveyed to the Director of Nursing and the Nursing Home Administrator on August 4, 2021, at 2:30 p.m. The facility failed to implement Resident R1's fall comprehensive care plan intervention. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/18/21 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/18/21

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of five residents reviewed (Resident R4) was free of neglect, which resulted in actual harm to Resident R4 during an improper transfer, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Findings include: Review of the facility policy and procedure titled, Abuse Prevention Program, last revised (MONTH) (YEAR), revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Review of the facility policy and procedure titled, Lifting Machine, Using a Mechanical, last revised (MONTH) (YEAR), revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Mechanical lifts may be used for tasks that require: Lifting a resident from the floor; Transferring a resident from bed to chair; Lateral transfers; Lifting limbs; Toileting or bathing; or Repositioning. Review of Resident R4's [DIAGNOSES REDACTED]. ability of the lungs to perform), Chronic Pai[DIAGNOSES REDACTED] (Persistent pain that lasts weeks to years), Abdominal Aortic Aneurysm (AAA - occurs when [MEDICAL CONDITION] or plaque buildup causes the walls of the abdominal aorta to become weak and bulge outward like a balloon, it could burst or rupture, causing intense abdominal or back pain, dizziness, nausea or shortness of breath), hypertension (elevated/high blood pressure), [MEDICATION NAME] Degeneration (a [MEDICAL CONDITION] condition affecting the central part of the retina and resulting in distortion or loss of central vision) and [MEDICAL CONDITION] (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of Resident R4's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 12, (YEAR), revealed the resident required extensive assistance with the assistance of two persons for bed mobility and total dependence with the assistance of two persons for transfers. Review of physician's orders dated (MONTH) 8, (YEAR), revealed an order for [REDACTED]. Review of Resident R4's care plan initiated (MONTH) 31, 2011, identified the resident as a risk for falls and risk for injury related to immobility, generalized weakness and need for Hoyer lift and assist of two for transfers. The interventions revealed to resident requires assist of two with Hoyer lift for transfers and is non-ambulatory. Review of Resident R4's clinical record revealed a physician note dated (MONTH) 9, (YEAR), at 7:30 a.m. indicated Patient complains of significant left knee pain. Patient states that during transfer she was hurt. The patient denies any other discomfort. The patient continues to have her chronic discomforts. The patient states she is unable to bend her knee. Left knee pain. X-ray ordered for left knee per physician. Review of the facility investigation documentation dated (MONTH) 10, (YEAR), at 12:30 p.m. revealed, Resident complained of knee pain and was assessed by MD (physician). A new order was received to X-ray the left knee. X-ray was completed and concluded a fracture involving left distal femur and proximal fibula with mild angulation (a fracture in which the fragments of bone are at angles to one another) and impaction (an impacted fracture occurs when the broken ends of the bone are jammed together by the force of the injury). MD and son made aware of the results of the X-ray and a new order was received to send resident to the ER (emergency room ) for evaluation. Upon receiving the X-ray results, an investigation was initiated. The resident was interviewed and stated her knee was hurting and she thinks it was when she was transferred. Upon investigation, a CNA (nursing assistant) from the evening shift admitted during a telephone interview that she transferred the resident on her own without the use of the Hoyer-lift. The investigation concluded that the CNA providing care did not follow the resident's plan of care. Review of the X-ray report dated (MONTH) 10, (YEAR), revealed results of the X-ray indicated, There is a fracture involving left distal femur and proximal fibula with mild angulation and impaction. The joint shows no dislocation. There is associated join effusion. Further review revealed, in conclusion, Acute appearing left knee fractures. Review of facility's investigation documentation dated (MONTH) 11, (YEAR), revealed nursing assistant, Employee E5, stated, I was assigned to Resident R4 on Tuesday, (MONTH) 8, (YEAR). At approximately 8:30 p.m. I'm not exactly sure of the exact time. I went to get resident from the lounge to put her to bed when I noticed she did not have a Hoyer sling underneath her. I asked a co-worker sitting in lounge what I should do, I did receive a answer. I proceed to put resident in to bed. I took her in the room placed her chair next to the bed with the front facing me and the back facing the closet. I then lifted her chair so that she was sitting up in a normal seated position as if she was in a chair or wheelchair. I then lowered her bed a little below the arm of the chair, then I lifted the resident under her arm and placed her on the bed I continued to hold her up with my left arm and brought her legs around with my right arm. After I placed resident in bed I proceeded to do p.m. care. Resident did complain as usual but it was nothing she did not do before. Once I finished her care I left the room finished my assignment. I came back to the resident's around approximately ten o'clock to check and change her she still seem find was not showing any signs of discomfort. Employee E5's interview with Director of Nursing undated, revealed employee stated she asked a co-worker for advice and she lead me in the wrong direction. Employee then stated, She transferred this resident by herself and without the Hoyer lift. Review of Resident R4's clinical record revealed a nursing progress note dated (MONTH) 10, (YEAR), at 8:46 p.m. indicated, Physician notified of resident's return for ER. New order for a follow up visit with ortho in two weeks and Aspirin 325 milligrams to be administered daily to prevent [MEDICAL CONDITION]. Reviewed pain medication and resident has [MEDICATION NAME] for pain already ordered. Further review of Resident R4's readmission nursing note dated (MONTH) 10, (YEAR), at 9:53 p.m. revealed, Resident returned from hospital at 1952 (7:52 p.m.). Vital signs B/P 182/101; Pulse 80; Respirations 16; Temperature 98.9 degrees Fahrenheit and Pulse ox 98% receiving oxygen via nasal cannula at 2 liters. Immobilizer on Lt (left) leg. Nurse to check leg q (every) shift. Assured her she was home and she could sleep now. Sleeping at this time. Further review of facility's investigation documentation dated (MONTH) 10, (YEAR), at 12:00 p.m. revealed, The investigation concludes that the CNA (nursing assistant) providing care did not follow the plan of care for transfers. Employee admitted that she transferred the resident by herself without the use of a lift. An interview with Director of Nursing on (MONTH) 14, (YEAR), at 12:45 p.m. confirmed that the nursing staff were not re-educated on the facility policy and procedure which included guidelines and steps for the use of a mechanical lifting device. Director of Nursing stated, It was just a reminder. Thirteen nursing assistants out of thirty-five nursing assistants employed at time of incident had signed the reminder document. An interview with Nursing Home Administrator and the Director of Nursing on (MONTH) 17, (YEAR), at approximately 11:45 a.m. confirmed the nursing assistant did not follow Resident R4's plan of care while transferring resident from chair to bed. The facility failed to provide documented evidence that nursing assistants employed at the time of incident were re-educated on Abuse Prevention and Proper Transfer Techniques The facility failed to ensure a resident was free of neglect, which resulted in actual harm to the resident after being improperly transferred from chair to bed, requiring transfer to the hospital emergency room and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 3/26/18, 9/5/17, 6/9/17, 12/19/16 28 Pa. Code 201.18(b)(1) Management Previously cited 3/26/18, 1/3/18, 9/5/17, 6/9/17, 2/16/17, 12/19/16 28 Pa. Code 201.18(b)(3) Management Previously cited 3/26/18, 9/5/17, 6/9/17, 12/19/16 28 Pa. Code 201.18(e)(1) Management Previously cited 9/5/17, 6/9/17, 12/19/16 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 3/26/18, 1/3/18, 9/5/17, 6/9/17, 2/16/17, 12/19/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/26/18, 9/15/17, 6/9/17, 2/16/17, 12/19/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 3/26/18, 9/5/17, 6/9/17, 12/19/16 28 Pa. Code 211.12(c) Nursing services Previously cited 3/26/18, 9/5/17, 6/9/17, 12/19/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/26/18, 1/3/18, 9/5/17, 6/9/17, 2/16/17, 12/19/16

Based on a review of clinical records, facility documentation and facility policy, it was determined that the facility failed to ensure that adequate monitoring and interventions were provided to prevent falls for one of 23 residents reviewed (Resident H1) resulting in actual harm to Resident H1. Findings include: Review of Resident H1's [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait). Review of Resident H1's active plan of care revealed that the resident's wheelchair was to be placed beside the bed, that the resident was to be encouraged to be out of the room and in common areas where the resident will have access to necessary supervision and that the resident was to be encouraged to stay in the lounge area where the resident can be observed. Review of Resident H1's clinical progress notes and facility documentation dated December 30, 2015, revealed that the resident sustained [REDACTED]. Further review of facility investigation into the fall incident revealed that the resident got out of bed to go to the bathroom and was found on the bathroom floor. The facility documentation also revealed that the resident's bed alarm (a device used to alarm staff that a resident is attempting to get out of bed) box was missing. Further review of Resident H1's nursing progress notes and facility documentation dated July 10, 2016, revealed that the resident was in a wheelchair in the lounge area and had fallen asleep in the wheelchair. Resident H1 had leaned forward after falling asleep and fell out of the wheelchair. Further review of Resident H1's active plan of care and progress notes failed to reveal that any updates and/or interventions were put into place after the July 10, 2016, fall with regard to ensuring the safety of Resident H1 and also failed to reveal that the resident was being observed and/or supervised while in the lounge area. Review of Resident H1's nursing notes dated July 15, 2016, revealed that the resident left the bed and attempted to ambulate to the bathroom and fell on the floor. Further review of Resident H1's nursing notes revealed that an X-ray of the resident's left hip was obtained per a physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident H1 was admitted to the hospital on July 15, 2016, requiring surgery to repair of the left femur fracture. Further review of the facility documentation in regard to Resident H1's fall incident that occurred on July 15, 2016, revealed that the, resident tried to get out of bed but the wheelchair was in the shower room; staff not able to get to resident prior to fall because bed alarm became disconnected from socket. The facility failed to ensure that proper monitoring and interventions were developed to prevent falls which resulted in Resident H1 falling and sustaining a fracture of the left femur requiring surgery and hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 02/04/16, 08/19/15, 03/10/15, 07/18/14 28 Pa. Code 201.18(b)(3) Management Previously cited 08/19/15 28 Pa. Code 211.5(f) Clinical records Previously cited 02/04/16, 08/28/15, 08/19/15, 07/18/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/19/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/04/16, 08/28/15, 08/19/15, 03/10/15, 07/08/14

Based on review of facility policy and clinical records and interview with staff, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status for one of 23 residents reviewed (Resident A2) resulting in actual harm to Resident A2. Findings include: Review of the facility policy, Weighing Residents revised November 2015, revealed that all residents will be weighed monthly. The Nurse Supervisor/Dietician/Diet Tech will review the resident weights and compare the current weight with the weight from the previous month. Residents that show a 5-pound weight loss or gain from the previous month will be reweighed within 24-48 hours. The Dietician or Dietetic Technician will review the resident weights each month and forward the weight change information to the nurse for notification of weight changes to the resident's responsible party on the Weight Change Notification Sheet. Review of Resident A2's annual Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated April 25, 2016, indicated that the resident had mild cognitive impairment and required extensive assistance of one person for eating. Review of Resident A2's weight record revealed a weight of 155.8 pounds on May 4, 2016. Review of the quarterly, Nutritional Assessment dated May 16, 2016, revealed that the resident was receiving a dysphagia diet (a diet designed for residents with inability/difficulty swallowing), fortified foods program (provides additional calories and protein), house supplement (a nutritional supplement) 4 ounces twice a day, Promod (a protein supplement) 30 milliliters twice a day, and a health shake (a nutritional supplement) once a day. The assessment indicated a body mass index (BMI - indicator of nutritional status) of 23.5 which is within the normal range of 19-25 and oral food intake met 26-75% of estimated needs. Review of the cart delivery schedule revealed that the main dining room opened at 12:00 p.m. and the food service started at 12:15 p.m. Review of Resident A2's meal intakes from May 23 to May 30, 2016, revealed that on four of seven days, the lunch intake was recorded between the time of 10:05 a.m. and 11:47 a.m., which was prior to the meal being served. Review of Resident A2's weight record revealed a weight of 132.7 pounds on June 1, 2016, which was then crossed out. A weight was recorded on June 3, 2016, of 128.8 pounds (27 pounds or 17.3% loss with a BMI of 19.0). Further review of the documentation revealed no evidence that the weight loss was addressed by the dietitian or that the family was notified. Review of the dietary change weight note of July 11, 2016, revealed that Resident A2's weight was 132.4 pounds on July 6, 2016, at which time the house supplement was increased to three times a day and the resident was to be weighed weekly. Review of weekly weights revealed a weight of 127.2 pounds on July 13, 2016, and 122.6 pounds on July 20, 2016, indicating continued weight loss. An interview with Licensed Staff, Employee E11, on July 22, 2016, at approximately 11:00 a.m. revealed that the initial monthly weight was completed on June 1, 2016, and the reweigh was done on June 3, 2016, even though the June 1, 2016, weight was crossed out. Employee E11 revealed that the list of monthly weights was received from nursing and reviewed. Employee E11 confirmed that Resident A2 had a significant weight loss and that intakes were being monitored, but no assessment was completed or interventions implemented. The facility failed to timely address a significant weight loss and implement interventions to prevent Resident A2's further weight loss resulting in actual harm to Resident A2. 28 Pa. Code 211.5(f) Clinical records Previously cited 02/04/16, 08/28/15, 08/19/15, 07/18/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/19/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 08/19/15, 07/18/14 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/04/16, 08/28/15, 08/19/15, 03/10/15, 07/08/14

Based on clinical record review and staff interviews, it was determined that the facility failed to provide tracheal suctioning in a timely manner for one of two residents reviewed, with a [MEDICAL CONDITION] (Resident CL4), resulting in actual harm to the resident. Findings include: Review of Resident CL4's closed clinical record revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Review of Resident CL4's [DATE] physician's orders [REDACTED]. Review of Resident CL4's nursing note dated [DATE] at 6:15 p.m., revealed, suctioning requested/received for small amount of white sputum. Husband present. Further review of the nursing documentation dated [DATE], completed by, licensed nursing staff Employee E2, indicated that Employee E2 was called by the nursing assistant, as resident had requested to be suctioned while the nursing assistant was talking to the resident. Further review of the nursing notes revealed the following entry, At 8:10 p.m., 95% (oxygen saturation level) on 4L (liters of oxygen) while resident observed as cyanotic (the appearance of a blue or purple coloration of the skin due to the tissues near the skin surface having low oxygen saturation); non-responsive. Time of death 20:20. Review of a nursing note dated [DATE], completed by licensed nursing staff, Employee E3, revealed, observed patient in bed at 20:10 cyanotic, pulse ox at 95% 911 called, return to room and patient was absent of respirations and heart rate. An interview conducted on February 2, 2016 at approximately 2:40 p.m., with nursing staff, Employee E4 revealed that on [DATE] at approximately 7:55 p.m. she was getting Resident CL4 ready for bed and the resident requested to be suctioned, and she was having difficulty breathing. Employee E4 walked out to the nurses' station and informed Employee E2, of this request and Employee E2 stated, she was just there and she (the resident) would have to wait. Employee E4 indicated during the interview that she returned to the room to inform the resident, and stated that the elapsed time was five to ten minutes for her return to the resident's room. Employee E4 noticed upon her return to the resident's room that the resident was turning purple and went to the nurses' desk a second time for help. Employee E4 stated that suctioning was not started at any time between the first time she notified the licensed nurse and upon her returned to the resident's room. An interview conducted on February 2, 2016 at approximately 12:48 p.m., with Employee E2, revealed that on [DATE], the nursing assistant reported that the resident was asking to be suctioned at approximately 8:05 p.m. Employee E2 stated during the interview that she was in the middle of doing some paper work and stated that the resident would have to wait until she was finished. Employee E2 stated she went back to Resident CL4's room approximately two or three minutes later and found the resident cyanotic. Employee E2 stated that at this time no suctioning was initiated and the house nursing supervisor, licensed nursing staff, Employee E3, called 911 and started CPR (Cardio [MEDICAL CONDITION] Resuscitation). An interview conducted on February 2, 2016 at approximately 1:00 p.m., with Employee E3, revealed that on [DATE], she was looking for Employee E2, and found her in Resident CL4's room at the foot of the resident's bed. Employee E3 indicated that the resident appeared to be struggling to breath. Employee E3 stated that Employee E2 verbalized that the resident, sometimes does this. Employee E3 ran to the nurses' station and proceeded to call 911. When Employee E3 returned to the resident's room, suctioning had not been initiated and Employee E3 began CPR. Further review of the Resident CL4's clinical record revealed a death certificate dated [DATE], that indicated the cause of death to be, respiratory arrest due to mucus plug. The facility failed to provide timely tracheal suctioning to Resident CL4 who was observed to be demonstrating signs and symptoms of respiratory distress which resulted in harm to Resident CL4. 28 Pa. Code 201.18 (b)(1) Management. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]