Every finding on record at Sunbury Skilled Nursing and Rehabilitation Center

Based on clinical record review and resident and staff interview it was determined that the facility failed to provide a written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for three of four residents reviewed for hospitalizations (Residents 1, 2, and 79); and failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer that included all the necessary contents for two of four residents reviewed for hospitalizations (Residents 2 and 79).Findings include: Interview with Resident 2 on May 5, 2026, at 1:02 PM revealed that it was necessary for him to go to the hospital because of his indwelling urinary catheter. Clinical record review for Resident 2 revealed nursing documentation dated November 17, 2025, at 12:21 PM that Resident 2's Foley (indwelling urinary catheter, flexible tubing inserted through the penis into the bladder to drain urine) tubing and urinary collection bag presented with frank blood draining, Resident 2 complained of lower pelvic and mid abdominal pain, and his abdomen was firm and tender to touch. He expelled two large liquid emesis (vomit) and had bilateral upper extremity tremors. Staff notified the doctor who instructed staff to send Resident 2 to the emergency room for evaluation. Nursing documentation dated November 17, 2025, at 12:37 PM indicated that Resident 2 was provided with written notice for the transfer, along with written information regarding the facility's bed hold policy. Nursing documentation dated November 20, 2025, at 8:11 PM (three days later) revealed that Resident 2 returned to the facility at 4:05 PM. Review of an untitled document dated November 21, 2025 (four days after Resident 2's transfer to the hospital and after his readmission to the facility) stipulated, Please let this letter serve as formal NOTICE that pursuant to regulatory requirements 42 C.F.R. 483.15 F623 (facility name, hereinafter facility) is discharging or transferring (Resident 2) from its facility effective November 17, 2025. The facility did not create or mail this notice as soon as practicable after Resident 2's transfer as it was created four business days after Resident 2's transfer to the hospital. The nursing documentation dated November 17, 2025, at 12:37 PM indicated that Resident 2 was provided with the written notice; however, the written notice was not dated until November 21, 2025. The written notice of transfer did not include: The name and address (mailing and email of the entity which receives appeal requests)How to obtain an appeal form and assistance in completing the formThe name, address (mailing and email) and telephone number of the Office of the State Long-Term Care OmbudsmanThe mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilitiesThe mailing and email addresses and telephone numbers of the agencies responsible for the protection and advocacy of individuals with mental disorders Review of an unsigned and undated, Bed Hold Notice of Policy and Authorization, document for Resident 2 revealed instructions to, Initial and date below next to each applicable area to indicate when the form was distributed/filed. The form included the fact that the facility distributed the form to Resident 2 on November 17, 2025; and distributed the form to Resident 2's Representative November 21, 2025 (four days after his transfer); which did not meet the requirement of within 24 hours in the cases of an emergency transfer. The document stipulated that if the hospitalization exceeded the number of days indicated (15 days), or is not covered, one could choose to guarantee the bed hold by following the private pay policy. The private pay policy information did not include the current daily rate for bed hold. The surveyor reviewed the above concerns regarding the provision of required notices upon Resident 2's transfer to the hospital during an interview with the Nursing Home Administrator and the Director of Nursing on May 7, 2026, at 2:10 PM. Clinical record review for Resident 1 revealed documentation dated March 15, 2026, at 8:00 AM that the resident had hematemesis (vomiting blood) and there was an order to send the resident to the emergency department. Clinical record review for Resident 1 dated March 15, 2026, at 2:32 PM revealed the resident had returned from the emergency department. Review of an untitled document (written notice of transfer) dated March 16, 2026, for Resident 1 revealed the resident was sent to the hospital on March 15, 2026. Clinical record review for Resident 79 revealed documentation dated April 18, 2026, at 8:03 PM that the resident had shortness of breath. Clinical documentation for Resident 79 dated April 18, 2026, at 8:42 PM revealed that the resident was sent to the hospital for evaluation. Review of the census documentation for Resident 79 revealed that the resident returned to the facility on April 23, 2026. Review of an untitled document (written notice of transfer) dated April 20, 2026, for Resident 79 revealed that the resident was sent to the hospital on April 18, 2026, for shortness of breath. Review of an unsigned and undated, Bed Hold Notice of Policy and Authorization, document for Resident 79 revealed that the document stipulated that if the hospitalization exceeded the number of days indicated (15 days), or is not covered, one could choose to guarantee the bed hold by following the private pay policy. The private pay policy information did not include the current daily rate for bed hold. The written notice of transfers for Residents 1 and 79 did not include: The name and address (mailing and email of the entity which receives appeal requests).How to obtain an appeal form and assistance in completing the form.The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.The mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities.The mailing and email addresses and telephone numbers of the agencies responsible for the protection and advocacy of individuals with mental disorders. The above information for Residents 1 and 79 was reviewed in a meeting with the Nursing Home Administrator on May 8, 2026, at 1:30 PM. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement range of motion devices for two of four residents reviewed for range of motion concerns (Residents 3 and 12).Findings include: Clinical record review for Resident 3 revealed a diagnoses list that included contracture (A medical condition characterized by the shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments. This leads to a loss of elasticity and a reduced range of motion in the affected area, which can significantly impact daily activities), left hand, and contracture, right hand, since November 21, 2025. An active physician order dated February 26, 2026, directed the use of, Restorative splints, No directions specified for order. Documentation Survey Report data (electronic documentation completed by nurse aide staff to attest to the provision of care) dated May 2026 included the intervention, Restorative Program Splint/brace assistance (number one): See care plan/kardex for program description. Review of Kardex (electronic list of interventions accessible to nurse aide staff to inform staff of resident care needs) instructions dated May 7, 2026, revealed instructions that included: Goal: Prevent contractures and maintain skin integrityRestorative splints: BUE (bilateral upper extremity) passive ROM (the movement of a joint or body part performed entirely by staff, without the resident) actively using their muscles) to all UE (upper extremity) joints bilaterallyPalm guards (type of hand splint or protective device designed to prevent skin damage to the palm by creating a barrier between the fingers and the palmar skin) to BUE at all times, remove for hygiene and with any signs skin irritation/redness terry cloth cone orthotics (type of hand cone device covered with terry cloth, designed to assist individuals with involuntary hand closure) to BUE hands, apply in AM and remove in PM. Remove during meals as needed and hand hygiene care as needed Documentation Survey Report data indicated that nurse aide staff documented the application of terry cloth cone orthotics to BUE hands in the AM and removal in the PM on May 6, 2026, at 1:58 PM and May 7, 2026, at 11:32 AM. Observation of Resident 3 on May 6, 2026, at 11:00 AM revealed no splint in either hand. Observation of Resident 3 on May 7, 2026, at 12:39 PM revealed no splint in either hand. Observation of Resident 3 on May 8, 2026, at 1:04 PM revealed no splint in either hand. Interview with Employee 9 (nurse aide) on May 8, 2026, at 1:23 PM revealed that she was the staff assigned to Resident 3's care on day shift on this date. Employee 9 stated that she placed splints in Resident 3's hands, however, described them as soft fabric. The description provided by Employee 9 was determined to be inter-dry (a soft fabric used for skin fold management; it removes moisture from skin-to-skin contact areas). Employee 9 denied knowledge of cone splints. Upon review of Documentation Survey Report data with Employee 9, she confirmed that her initials on the day (7:00 AM to 3:00 PM) shift on May 2, 2026, attested to the application of the cone splints. Observation of Resident 3's room with Employee 9 on May 8, 2026, at 1:25 PM revealed a white hand splint device on the top of Resident 9's bedside stand. The surveyor reviewed the concerns regarding Resident 3's hand splint omissions during an interview with the Director of Nursing on May 8, 2026, at 1:30 PM. Clinical record review for Resident 12 revealed her diagnoses list included left hand contracture since September 24, 2025. Physician orders for Resident 12 included an active physician order dated June 14, 2025, for staff to apply inter-dry to Resident 12's left palm prior to splint application for prevention/protection every day shift. Review of Resident 12's Treatment Administration Record (TAR, electronic documentation by licensed staff to attest to the implementation of treatments) dated March and April 2026 revealed that licensed staff initialed the application of inter-dry to Resident 12's left palm prior to a splint application for prevention/protection every day shift. The documentation revealed Employee 1 (licensed practical nurse) initialed the treatment as completed on day shift May 5, 6, and 7, 2026. Licensed staff initialed the inter-dry as completed on day shift daily March and April 2026. Observation of Resident 12 on May 6, 2026, at 9:57 AM revealed that she could not fully open the fingers of her left hand from a fist position. Interview with Resident 12 on the date and time of the observation indicated that she did not know where staff stored her splint device. There was no splint or fabric in Resident 12's left hand. Review of Documentation Survey Report for Resident 12 dated March, April, and May 2026 revealed that nurse aide staff documented the application of a splint on day shift (7:00 AM to 3:00 PM). Observation of Resident 12 on May 7, 2026, at 12:51 PM with Employee 2 (nurse aide) verified Resident 12 had no splint or fabric in her left hand. Interview with Employee 1 and the Director of Nursing on May 7, 2026, at 4:30 PM revealed that the physician order for Resident 12's hand splint was transcribed incorrectly as an intervention for day shift nurse aides, however, evening and night shift nurse aides were to implement the task. The interview confirmed that day shift nurse aide staff were initialing the intervention as implemented, however, the device was not in use during day shift. The evening and night shift nurse aides were not documenting the implementation of the task. Employee 1 stated that she believed that her intervention was for implementation upon the removal of the splint, however, the intervention she documented implementation for instructed to apply to Resident 12's left palm prior to a splint application for prevention/protection every day shift. Nurse aide staff documented the application of the splint on day shift March, April, and May 2026. Licensed nursing staff documented the completion of the treatment before the application of the splint March, April, and May 2026. No staff documented the application of splints evening or night shifts. 483.25 Quality of CarePreviously cited deficiency 6/13/25 28 Pa. Code 211.12(d)1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility.Findings include: Initial tour of the facility's main kitchen with Employee 19, Dietary Manager, on May 5, 2026, at 9:09 AM revealed the following: A package of waffles in a freezer with no evidence of a date of when they were placed there, opened, or needed to be used by. A package of frozen fish in a freezer. The written date on the item was smudged and unreadable. An open box of salt that was stored on a shelf with spices. The package indicated to use within three years of opening. The item was not dated with an open date. The surface of the shelf was covered with a granule-like substance. There were four packaged rolls of ground beef in a stainless-steel pan located on the bottom shelf of a refrigerator. Employee 19 indicated they were thawing for use later. These items were located next to four, one gallon plastic containers of milk. One of the containers of milk was in direct contact with the pan holding the thawing meat. There was a black colored bag covering a mixer. The bag had an accumulation of dust, hair, and food particles on it. The hood over the stove had a build-up of dust on the inner vents and noted dust on the fire suppression nozzles over the stove. The three-compartment sink was filled and had various cookware in it to be washed. The sanitizer strips used for testing expired in July 2022. An empty food tray cart identified as clean per Employee 19 had a build-up of dried stains located on the underside of the supports used to hold the trays. The curtain that covered a window above the three-compartment sink had stains and was discolored. The top of the window frame had a significant build-up of dust. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 2:00 PM, and May 7, 2026, at 2:00 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview it was determined that the facility failed to ensure complete and accurate clinical records for four of 26 residents reviewed (Residents 3, 5, 10, and 83). Findings include: Clinical record review for Resident 5 revealed that the Immunization tab in the resident's electronic health record (EHR) information indicated that Employee 8 (registered nurse/infection control prevention coordinator) confirmed on October 21, 2025, that education regarding the risks and benefits of the influenza vaccine was provided to Resident 5; and that he refused the immunization. Review of a Patient/Resident Influenza Vaccine Informed Consent document signed by Employee 8 on October 21, 2025, indicated that staff obtained verbal consent to administer the influenza vaccine to Resident 5. Review of Resident 5's Medication Administration Record (MAR, electronic documentation of the administration of medications by licensed staff) dated October 2025 revealed that staff documented Resident 5's refusal of the influenza immunization on October 7, 2025, at 6:27 PM (two weeks before the documentation in Resident 5's EHR Immunization tab of the education regarding the risks and benefits of the immunization and the verbal consent by Resident 5's responsible party). Interview with the Nursing Home Administrator and the Director of Nursing on May 7, 2026, at 2:15 PM confirmed the above findings for Resident 5. They indicated that Resident 5 and his responsible party received education regarding the vaccine's risks and benefits before the attempt to administer the vaccine and staff continued to attempt to administer the vaccine in response to Resident 5's refusals, and that the documentation was incorrect. It was then confirmed that the data entries in the resident's Immunization tab of the EHR could be updated/changed without any date, time, or electronic signature of staff altering the entry as evidenced by Resident 5's influenza immunization information that was updated weeks after his influenza immunization refusal. An additional Immunization Report for Resident 5 provided by the facility via hard copy recorded that staff (no signature or identifier recorded) provided education regarding the 2025-2026 influenza immunization's risks and benefits on October 22, 2025; and that Resident 5 refused multiple attempts to administer the vaccine. Clinical record review for Resident 10 revealed an active physician order dated October 28, 2025, to not resuscitate (DNR, do not provide chest compressions or breathing assistance in the event of no pulse or absence of breathing) in the event of a medical emergency. Review of Resident 10's physical chart revealed a POLST (Physician Order for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) signed by the certified registered nurse practitioner on September 16, 2025, did not have a signature of Resident 10 or her responsible party. Interview with Employee 1 (licensed practical nurse) on May 6, 2026, at 12:00 PM confirmed that the POLST available in Resident 10's clinical record failed to include her responsible party's signature. Interview with Employee 10 (registered nurse/unit manager) on May 6, 2026, at 12:02 PM verified Resident 10's POLST did not include a signature of the resident or the resident's responsible party. Employee 10 confirmed that if the resident were to transfer out of the facility in an emergency, the facility would send the POLST that, in Resident 10's situation, would not have her responsible party's signature to indicate an acknowledgement or agreement with the end-of-life decisions. The surveyor reviewed the above concerns regarding Resident 10's incomplete POLST during an interview with the Director of Nursing and the Nursing Home Administrator on May 6, 2026, at 2:00 PM. Clinical record review for Resident 3 revealed an active physician's order dated March 30, 2026, for DNR, comfort care. Review of Resident 3's physical chart revealed a POLST signed only by the medical practitioner on April 3, 2026. Interview with Employee 1 on May 6, 2026, at 11:42 AM confirmed that no resident or responsible party signed Resident 3's POLST form and no co-signatures of staff on the form attested that the end-of-life decisions recorded on the form were those of Resident 3 and/or her responsible party. Interview with Employee 10 on May 6, 2026, at 12:02 PM confirmed that no staff attested to Resident 3 or her responsible party's participation in developing the POLST form (missing signatures of staff). Employee 10 also verified that if Resident 3 were to have a medical emergency, the POLST form would relay care wishes to the practitioner; there would be no accompanying nurse progress notes that would indicate what Resident 3 or her responsible party decided for end-of-life care. The facility provided a revised POLST form for Resident 3 on May 7, 2026, at 2:18 PM (following the surveyor's questioning) that now included two staff signatures that were not dated. The Director of Nursing confirmed on May 7, 2026, at 2:18 PM that staff did not date when the document was altered to include two staff signatures. Clinical record review for Resident 83 revealed a POLST in her physical chart that was signed by her sister/responsible party; however, did not include a practitioner signature. Interview with Employee 11 (registered nurse) on May 6, 2026, at 11:56 AM confirmed that the POLST available for Resident 83 did not include a practitioner signature. Resident 83's POLST also did not contain staff signatures. Interview with Employee 10 on May 6, 2026, at 12:02 PM confirmed the POLST available to convey end-of-life wishes in the event of an emergency did not contain a physician or staff signatures. An active physician order dated September 23, 2025, instructed staff to not resuscitate (DNR) Resident 83 in the event of a medical emergency. 28 Pa. Code 211.5(f)(i)-(xi)(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interview and review of available employee immunization records it was determined that the facility failed to maintain documentation of the COVID-19 vaccination status of each staff member for four of four employees reviewed (Employees 4, 5, 6, and 7).Findings include: The surveyor requested documentation of the facility's tracking of employees' current COVID-19 immunization status during an interview with the Director of Nursing and the Nursing Home Administrator on May 6, 2026, at 2:00 PM; with the Nursing Home Administrator on May 7, 2026, at 6:10 PM; and with Employee 8 (registered nurse/infection control prevention coordinator) on May 8, 2026, at 10:25 AM. Interview with Employee 8 on May 8, 2026, at 10:56 AM indicated that the facility maintains staff immunization documentation in an electronic record keeping system. Employee 8 indicated that once the surveyor provided the names of employees for review, she would be able to access the records for those staff. Interview with Employee 4 (housekeeping/assistant manager) on May 8, 2026, at 11:54 AM revealed that she believed that she had two or three COVID-19 immunization boosters; the last immunization was received September 14, 2022. Interview with Employee 5 (floor technician) on May 8, 2026, at 11:56 AM revealed that he had two COVID-19 immunization boosters; he approximated that his last immunization was in the year 2021. Interview with Employee 6 (laundry district manager) on May 8, 2026, at 11:57 AM revealed that she believed that she was fully vaccinated for COVID-19; however, stated that she received her last COVID-19 immunization at a local grocery store in the year 2024. Employee 6 denied receipt of a COVID-19 immunization for the 2025-2026 season. Interview with Employee 7 (housekeeping) on May 8, 2026, at 11:58 AM revealed that he chose not to receive COVID-19 immunizations. Interview with Employee 8 on May 8, 2026, from 12:15 PM to 12:30 PM revealed that she was unable to access COVID-19 immunization documentation stored in the facility's electronic record system for staff immunization documentation for Employees 4, 5, 6, and 7. Employee 8 confirmed that Employees 4, 5, 6, and 7 are employees provided through a contracted company for housekeeping and laundry services. Employee 8 was able to access her own COVID-19 immunization documentation at that time; however, the names of the four employees interviewed were not recorded in the electronic record. The surveyor reviewed the concern that the facility's staff immunization electronic recording system did not contain documentation of the COVID-19 immunization status for Employees 4, 5, 6, and 7; and could only provide Employee 8's information during an interview with the Director of Nursing and the Nursing Home Administrator on May 8, 2026, at 12:40 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on clinical record review, review of select facility policies and procedures, observation, and resident and staff interviews. it was determined that the facility failed to promote resident choices about aspects of his or her life in the facility that are significant to the resident regarding food brought in from home for one of 26 sampled residents (Resident 65). Findings include: The policy entitled Food Brought in for Patients/Residents, last reviewed without changes August 27, 2025, revealed food and beverages may be brought in from outside the facility for individual patients/residents but must not be offered to other residents. Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food may be reheated in microwaves by staff only. Interview with Resident 65 on May 8, 2026, at 10:22 AM revealed his daughter brought him some homemade gluten free spaghetti and the facility would not let him eat it stating they will not reheat food brought in from home. Interview with Employee 20 (licensed practical nurse) on May 5, 2026, at 12:06 PM revealed that the facility removed the microwaves from the nursing units. Clinical record review for Resident 65 revealed nursing documentation dated April 9, 2026, at 4:30 PM revealed the interdisciplinary team reviewed Resident 65's behavioral incident on April 8, 2026. Documentation revealed Resident 65 became agitated when informed that outside food (spaghetti brought from family) could not be reheated per facility infection control and food safety guidelines. Resident 65 punched the wall in his room, sustaining a small open area to the right hand. Interview with the Nursing Home Administrator and Director of Nursing on May 8, 2026, at 9:27 AM confirmed the pantries for the first and second Floor Nursing Units did not contain a device for heating food. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 205.25 (b) Kitchen

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 26 residents reviewed (Resident 12).Findings include: Clinical record review for Resident 12 revealed her diagnoses list included left hand contracture (A medical condition characterized by the shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments. This leads to a loss of elasticity and a reduced range of motion (ROM) in the affected area, which can significantly impact daily activities.) since September 24, 2025. Physician orders for Resident 12 included an active physician order dated June 14, 2025, for staff to apply inter-dry (a soft fabric used for skin fold management; it removes moisture from skin-to-skin contact areas) to Resident 12's left palm prior to splint application for prevention/protection every day shift. Review of Resident 12's Treatment Administration Record (TAR, electronic documentation by licensed staff to attest to the implementation of treatments) dated March and April 2026 revealed that licensed staff initialed the application of inter-dry to Resident 12's left palm prior to a splint application for prevention/protection every day shift. Observation of Resident 12 on May 6, 2026, at 9:57 AM revealed that she could not fully open the fingers of her left hand from a fist position. Interview with Resident 12 on the date and time of the observation indicated that she did not know where staff stored her splint device. Review of Documentation Survey Report (electronic documentation by nurse aide staff to attest to the care provided to a resident) data for Resident 12 dated March, April, and May 2026 revealed that nurse aide staff documented the application of a splint on day shift (7:00 AM to 3:00 PM). A Medicare five-day MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], assessed Resident 12 with ROM (range of motion) impairment of her bilateral upper extremities. Staff assessed Resident 12 as dependent on staff for eating, oral hygiene, toileting, upper and lower body dressing, personal hygiene, transfers, and bed mobility. An admission MDS dated [DATE], assessed Resident 12 with ROM impairment of her bilateral upper extremities. Resident 12 remained dependent on staff for care; Resident 12 was not independent for any care noted above. Quarterly MDS assessments dated June 8, 2025, September 7, 2025, and December 7, 2025; and an annual MDS assessment dated [DATE], no longer assessed a ROM impairment for Resident 12's upper extremities. Resident 12 required supervision/touching assistance for eating and continued to be dependent on staff for oral hygiene, toileting, upper and lower body dressing, personal hygiene, transfers, and bed mobility. A plan of care created January 7, 2026, to address Resident 12's splint and brace use, noted that, Patient cannot apply and remove splint/brace r/t (related to) functional deterioration. The surveyor reviewed the concern regarding MDS accuracy for Resident 12 during an interview with the Nursing Home Administrator and the Director of Nursing on May 8, 2026, at 9:40 AM. Interview with Employee 3 (registered nurse assessment coordinator) on May 8, 2026, at 11:12 AM confirmed that Resident 12 had a diagnosis of a left hand contracture, had a plan of care that identified her functional limitation, had MDS assessments that confirmed she required staff assistance for all activities of daily living, that staff documented the application of a splint to her left hand, and she had physician ordered treatment to address her potential for left hand injury (inter-dry). The interview confirmed that the facility had no information or evidence that Resident 12 had a resolution of her range of motion impairment identified on her MDS assessments until June 2025. The interview confirmed that the RAI (Resident Assessment Instrument, MDS) instructions to complete the ROM section instructs that ROM deficits capture the limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a cardiac pacemaker for one of 26 residents reviewed (Resident 1). Findings Include: Clinical record review for Resident 1 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart), sick sinus syndrome (a malfunctioning of the heart that impacts the heart's natural pacemaker node), and atrial fibrillation (an irregular heart rhythm). Medical provider documentation for Resident 1 dated May 5, 2026, at 1:00 AM revealed that the resident has a pacemaker. Cardiology documentation dated September 5, 2025, at 3:39 PM revealed that Resident 1 had a leadless pacemaker implanted in May 2022. Review of Resident 1's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 2:00 PM. A follow-up observation of Resident 1's room on May 8, 2026, at 9:11 AM revealed that there was a transmittal device on the resident's dresser located next to the bed. A concurrent interview with Employee 20, licensed practical nurse, revealed that the device was utilized to transmit data from the resident's pacemaker so that it can be remotely monitored. A follow-up review of Resident 1's care plan revealed a care plan created on May 6, 2026, (after the initial surveyor findings), that noted the resident is at risk of complications related to the pacemaker / internal defibrillator. The care plan did not address the transmittal device and/or associated care. The additional information for Resident 1 was reviewed with the Nursing Home Administrator and Director of Nursing on May 8, 2026, at 12:46 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, observation, and resident and staff interview, it was determined that the facility failed to appropriately assess a side rail for entrapment zone risks and obtain informed consent for side rail use for one of six residents reviewed for accident hazards (Resident 69).Findings include: Clinical record review for Resident 69 revealed a diagnosis list that included muscle weakness and hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 10, 2026, revealed that facility staff assessed Resident 69 as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. Observation and concurrent interview with Resident 69 on May 6, 2026, at 10:30 AM revealed a side rail that was attached to the resident's right side of the bed. The side rail appeared to be in the down position but was visible several inches above the mattress. The resident reported she uses the side rail to get in and out of bed. Based on the interview that Resident 69 reported she utilizes the side rail to get in and out of bed, documentation (consents, assessments, entrapment zone measurements) was requested by the surveyor during a meeting with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 2:00 PM. The facility reported the related documentation should be in the electronic health record (EHR). Review of the EHR for Resident 69 revealed no documentation for Resident 69 related to consent for use of the side rail and any entrapment zone measurements. Therapy documentation for Resident 69 provided by the facility dated May 23, 2025, at 12:03 PM revealed an assessment summary that noted the resident was referred to therapy services and has received a bed assist rail. The documentation noted the resident is demonstrating ability to place and remove rail to bedside height safely and the railing has improved the resident's ability to perform bed mobility from her baseline. Physical Therapy Discharge Summary documentation provided by the facility dated June 12, 2025, at 2:55 PM noted, the resident has received services to ensure she is safe with the use of bed assist railing and has demonstrated good safety and management of railing. Facility documentation titled, Bed Safety Evaluation - V2, dated March 19, 2026, at 11:43 AM revealed documentation that questioned if there was a gap between the head or foot board and mattress which was marked as no. There was no further indication that any additional zones were assessed. The staff selected that All questions have been answered 'yes' - RAILS/DEVICES Are Not Required. A request for any entrapment zone measurements or documentation of informed consent for use of the side rail was made during a meeting with the Nursing Home Administrator and Director of Nursing on May 7, 2026, at 2:00 PM and May 8, 2026, at 9:45 AM. An interview with Employee 29, Director of Therapy, on May 8, 2026, at 9:38 AM revealed that therapy does the resident safety assessments for any bed rails and not entrapment zone assessments. An interview with Employee 21, maintenance staff, on May 8, 2026, at 12:37 PM revealed that Employee 21 could find no entrapment zone checks related to Resident 69's side rail. Employee 21 revealed that he just assessed the side rail after it was brought to the facility staff's attention by the surveyor and provided a form titled, Bed System Measurement Device Test Results Worksheet, dated May 8, 2026, that indicated the resident's right-side rail was just assessed. Employee 21 indicated that he was not aware that the side rail was on the bed. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 8, 2026, at 12:45 PM. The facility reported they could not find any informed consents related to Resident 69's side rail. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with a PICC line, and catheter care, for four of four employees reviewed for competencies (Employees 1, 22, 23, and 24).Findings include: A review of the facility documentation revealed that the facility had a total of five residents with indwelling catheters (insertion of a tube into the bladder to remove urine), and one resident with a discontinued PICC line (peripherally inserted central catheter, a long flexible tube inserted into a vein in the arm that reaches a large central vein near the heart). A request for nursing staff competencies for PICC line and catheter care revealed the facility was unable to provide these competencies for Employees 1 and 24 (LPN, licensed practical nurse), and Employees 22 and 23 (RN, registered nurse). Interview with Employee 28 (registered nurse educator) on May 8, 2026, at 1:21 PM confirmed that the facility could provide no documentation that ensured Employees 1, 22, 23, and 24 had specific competencies and skill sets to care for the residents' needs listed above. The findings were reviewed with the Director of Nursing on May 8, 2026, at 1:25 PM. 28 Pa Code 201.20(a) Staff development

Based on observations and resident and staff interviews, it was determined that the facility did not provide food in accordance with resident preferences for one of 26 residents reviewed (Resident 47).Findings include: The facility policy entitled Dining and Food Preferences, last reviewed without changes August 27, 2025, revealed individual dining, food, and beverage preferences are identified for all residents. The dining services director, or designee will interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose of this interview will be to identify individual preferences for dining location, mealtimes, including times outside of the routine schedule, and food and beverage preferences. The food preference interview will be entered into the medical record. Food and fluid preferences will be entered in the menu management software system. Clinical record review revealed the facility admitted Resident 47 on April 1, 2026. Interview with Resident 47 on May 5, 2026, at 2:35 PM revealed that Resident 47 told staff she needs gravy, or extra sauce with all her meals due to having swallowing issues. Resident 47 said she frequently cannot eat the meal provided and must ask for a toasted cheese due to the kitchen not providing her extra sauce or gravy. Resident 47 stated that no one has talked to her about her food preferences since admission. Observation of Resident 47's lunch meal on May 6, 2026, at 12:22 PM revealed that Resident 47 did not receive any gravy or extra sauces, and her meal ticket did not note her preferences. Interview with Employee 19 (dietary manager) on May 8, 2026, at 1:13 PM confirmed that no one interviewed Resident 47 regarding her food preferences until after the surveyor's questioning. Employee 19 confirmed that she was asked to add extra gravy to Resident 47's meal ticket earlier that day. Nursing documentation dated May 8, 2026, at 11:39 AM revealed the registered dietitian spoke with Resident 47 regarding her meal preferences. Reviewed findings with the Nursing Home Administrator and Director of Nursing on May 8, 2026, at 1:25 PM. They confirmed the facility failed to obtain Resident 47's meal and beverage preferences within 72 hours of her admission to the facility. 28 Pa. Code 211.6 (a) Dietary services

Based on observation and staff interview, it was determined that the facility failed to provide a clean environment on one of two nursing units (Second Floor, Resident 108), and maintain facility equipment in the facility's main kitchen. Findings include: Observation on June 10, 2025, at 12:08 PM of Resident 108's room revealed a two-tiered cart beside the bed that housed a humidification machine on the top rack, a cardboard box, a stack of inverted plastic cups, and a jug of water on the bottom rack. The cart appeared soiled with dust and debris and had a dried white substance splashed on it. Observation of Resident 108's room on June 11, 2025, at 9:59 AM revealed the humidification machine was in use and the cart still appeared soiled with dust and debris and the dried white substance remained. Interview with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:28PM reviewed the above noted items regarding Resident 108. Observation in the facility's main kitchen on June 10, 2025, at 9:07 AM revealed multiple metal shelves inside several two-door storage coolers contained exposed rusted metal in areas where the protective coating was worn off the shelves. An observation of a large dining/activity room located on the second-floor nursing unit (South end) on June 12, 2025, at 11:47 AM revealed a set of lower cabinets by the sink area with several rolling pins, mixing bowls, and measuring cups stored in it. The cabinets appeared very worn, and the interior of the cabinet doors and interior base of the cabinets was significantly soiled with brown debris, dust, crumbs, and was sticky to touch. The above information regarding the cooler shelving and second floor dining/activity area was reviewed with the Nursing Home Administrator on June 12, 2025, at 2:00 PM. 483.10(i)(1)(2) Safe/clean/comfortable/homelike Environment Previously cited 7/10/24 28 Pa. Code 201.18 (e)(2.1) Management

Based on review of select facility policy and procedures, observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure and confidential personal and medical records on the ground floor of the facility and one of two nursing units (First Floor Nursing Unit North Wing). Findings include: A review of the facility policy titled, Safeguarding and Storage of Health Information Records, last reviewed on August 21, 2024, revealed that the company will maintain reasonable administrative, technical, and physical safeguards to protect the privacy of protected health information (PHI) from use or disclosure that is a violation of federal and/or state regulations. The purpose of the policy was noted to limit unauthorized access of PHI. Further review of the facility policy revealed a section titled Procedure, that noted procedures such as the following: protect all health information records from damage, loss, destruction, or unauthorized use; limit viewing access by unauthorized personnel as well as visitors by returning records to their designated storage location or closing when not in use; limit access to all other methods of storage of health information, including medication administration record and treatment notebooks, close notebooks when not in use to limit unauthorized access; overflow or discharge records must be filed in a systemic manner, either alphabetically or numerically, in a location that ensures the privacy and security of the information; file in a secure area such as a lockable cabinet or room/office that is not shared with other staff; when discharge records are stored in alternate storage areas or with long term storage companies: limit access to only authorized personnel; ensure the security of the paper documents and protect them from elements such as moisture, water, rodents, and fire. Observation on the North Wing of the First Floor Nursing Unit on June 10, 2025, at 10:24 AM revealed a computer at the nurse's station that was logged into the resident electronic charting software. There were no staff working at the computer or present in the immediate area upon initial observation, leaving the electronic medical record logged into an unsecured area (the electronic health record is password protected and must be logged into and out of to help ensure confidentiality). Continued observation on June 10, 2025, at 10:33 AM revealed that the computer was still logged into the electronic charting software. There was no staff member observed working at the computer and multiple unidentified staff were observed walking by the open charting program. Continued observation on June 10, 2025, at 10:47 AM revealed that the computer was still logged into the electronic charting software and Employee 2, licensed practical nurse, proceeded to return to the nurse's station and sit down at the computer. Observation on North Wing of the First Floor Nursing Unit on June 11, 2025, at 10:25 AM revealed a computer at the nurse's station that was logged into the resident electronic charting software. There were no staff working at the computer or present in the immediate area upon initial observation and the residents' electronic medical record was accessible and unsecured. Employee 2's name was noted as the user logged into the charting software. Continued observation on June 11, 2025, at 10:30 AM revealed an unidentified staff member return to the nurse's station and upon surveyor questioning about the unsecured and accessible open charting software, the employee proceeded to summon Employee 2 who returned to the nurse's station and began working at the computer. Observation on June 12, 2025, at 10:32 AM revealed an overflowing box of papers with the lid ajar just off the main hallway that runs adjacent to the facility's main kitchen. The box was open, and the contents were unsecured and accessible to anyone passing by (upon observation, housekeeping staff were observed wheeling garbage cans by the area). Further observation revealed the box contained various medical records and clinical documentation with identifiers of residents. An interview with Employee 3, medical records, on June 12, 2025, at 10:39 AM revealed that the box contained medical records that are awaiting pick-up from a contracted off-site storage company. However, it was unclear when the storage company would be coming and could be as early as today or weeks from now. The facility failed to ensure residents' rights to secure and confidential personal and medical records. 28 Pa. Code: 201.18(e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of 24 residents reviewed (Resident 317). Findings include: Clinical record review for Resident 317 revealed a diagnosis list that included atrial fibrillation (an irregular and sometimes rapid heart rhythm that can lead to complications such as stroke and heart failure) and essential hypertension (high blood pressure). Review of Resident 317's current care plan revealed the resident is at risk for cardiovascular symptoms or complications related to low blood pressure due to medications with parameters in place. A review of the current physician orders for Resident 317 revealed an order dated March 1, 2025, for Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give half a tablet by mouth one time a day for hypertension. Hold for a systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100 or pulse less than 60. A review of the Medication Administration Record (MAR) for June 2025, for Resident 317 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following dates: June 1, the resident's pulse was documented as 56 June 2, the pulse was documented as 56 June 9, the pulse was documented as 56 June 10, the pulse was documented as 51 June 11, the pulse was documented as 51 There was no documentation for Resident 317 why the medication was administered outside of the specific physician ordered parameters. The above information for Resident 317 was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 11, 2025, at 1:45 PM. Further review of Resident 317's medical record revealed that staff documented on the MAR for June 12, 2025, that the Metoprolol was administered despite a corresponding blood pressure noted as 90/54. The above information for Resident 317 for the Metoprolol administration on June 12, 2025, was reviewed in a meeting with the NHA and DON on June 12, 2025, at 2:00 PM. 483.25 Quality of Care Previously Cited 7/10/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Resident 15). Findings include: In an interview and observation of Resident 15 on June 10, 2025, at 11:42 AM the resident indicated he attended dialysis outside the facility three days a week and that his access site was in his arm. Concurrent observation of Resident 15's room did not reveal any emergency supplies used to control bleeding such as sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape in the resident's room readily available should the resident start bleeding from his dialysis access site. With the resident's permission to look inside his closet there was also no evidence of any emergency supplies in Resident 15's closet. Clinical record review for Resident 15 revealed the resident was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) three days a week outside the facility and the resident had an AV (arteriovenous) fistula (a surgically created connection between and artery and a vein) for dialysis. In a follow up observation of Resident 15's room on June 11, 2025, at 9:35 AM, Employee 1, licensed practical nurse, checked Resident 15's closet, bedside drawers, and bag the resident transported back and forth to dialysis, and could not locate emergency supplies. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 11, 2025, at 12:37 PM. 483.25 (I) Dialysis Previously cited 7/10/24 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 18). Findings include: Clinical record review for Resident 18 revealed that the facility admitted her on May 31, 2014. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to her clinical record on October 1, 2022. A review of Resident 18's significant change Minimum Data Set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 18's current care plan entitled, Cognitive loss as evidenced by forgetfulness related to dementia last revised on February 20, 2020, and her care plan entitled At risk for behavior symptoms due to dementia initiated on April 17, 2025, failed to identify individualized person-centered approaches to address Resident 18's dementia and cognitive loss to include indications of distress and how she communicates unmet needs such as pain, discomfort, hunger, thirst and frustration. The findings were reviewed with the Nursing Home Administrator on June 13, 2025, at 10:30 AM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (First Floor Nursing Unit North Wing; Resident 22). Findings include: The facility's medication error rate was 7.14 percent based on 28 medication opportunities with two medication errors. Observation of Resident 22's medication administration pass on June 12, 2025, at 9:05 AM revealed that Employee 4, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 4 went to Resident 22's room and placed one drop of Brimonidine Tartrate-Timolol Ophthalmic Solution 0.2-0.5% (a medication administered via eye drops to lower the pressure in the eyes known as intraocular pressure) into each of the resident's eyes. Review of Resident 22's clinical record revealed a physician's order dated March 6, 2025, that noted Brimonidine Tartrate-Timolol Ophthalmic Solution (0.2-0.5%) instill one drop in the right eye two times a day for glaucoma (an eye condition that can lead to vision loss or blindness and is often associated with increased pressure in the eye). A follow-up interview with Employee 4 on June 12, 2025, at 9:23 AM confirmed that the drops were administered in both eyes at the time of the medication pass and are only ordered for the right eye. Employee 4 administered one lactase enzyme supplement (an enzyme to help break down lactose in milk products to help treat lactose intolerance) to Resident 22. Resident 22 did not have any food present at the time of the administration. Review of Resident 22's clinical record revealed a physician's order dated March 25, 2025, that noted Lactaid Oral Tablet (Lactase) give one tablet by mouth every day with meals at 7:30 AM/11:30 AM/4:30 PM for lactose intolerance. A review of the instructions on the bottle of the medication revealed to swallow the capsules with the first bite of dairy food, and the medication can be used every day with every meal. Resident 22's Lactaid Oral Tablet (Lactase) was not given with a meal. An interview with Employee 5, registered nurse, on June 13, 2025, at 12:01 PM revealed that Resident 22's family sometimes brings in breakfast for her. An interview with Resident 22 on June 13, 2025, at 12:03 PM revealed that the resident's family did bring in breakfast for her on June 12, 2025, and reported the time as 7:20 AM. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:00 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (First Floor Nursing Unit) and failed to ensure the security of a resident's prescription for a controlled substance one of one nursing units reviewed (Second Floor Nursing Unit, Resident 45). Findings include: Observation during the medication pass on the North Hall of the First Floor Nursing Unit on June 12, 2025, at 9: 15 AM revealed a medication cart being utilized by Employee 4, licensed practical nurse. Observation of the medication cart revealed the following: There were several unsecured and unidentified medication tablets found in the bottom of the drawers that included: a brown oblong tablet, a pink colored oblong tablet, and a white colored oblong tablet. A drawer of the medication cart had a container of individually wrapped supplemental vitamin chews that contained a pink colored oblong medication tablet and a yellow colored oblong medication tablet. A concurrent interview with Employee 4 revealed that it was unclear what the unsecured medications were. The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 2:00 PM. Review of Resident 45's clinical record on June 12, 2025, at 12:00 PM revealed two loose prescriptions for Oxycodone (an opioid medication used to treat severe pain) 5 milligrams as needed every four hours for moderate to severe pain. One of the prescriptions was dated June 2, 2025, and the other was dated June 5, 2025. The prescriptions were not defaced, and they were easily removable from the clinical record. Resident 45's clinical record was located behind the nurse's station with all the other resident records who reside on the nursing unit. The nurse's station had a slide over lock to a door that did not require a key or code to unlock and was easily accessible to all staff The above information regarding Resident 45's prescriptions was reviewed, and the prescriptions were given to the Nursing Home Administrator on June 12, 2025, at 12:15 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents, family members, and legal representatives in the main lobby of the facility and on one of two nursing units (First Floor Nursing Unit). Findings include: Observation of the main lobby of the facility on June 10, 2025, at 2:31 PM and the First Floor North Nursing Unit resident lounge at 2:40 PM revealed a binder that should contain the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binders revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder; however, did not place the Statement of Deficiencies (Form CMS-2567) as required. The deficiency letters placed in the binders also noted the specific resident identifiers and associated resident names used for any cited deficiencies that were listed in the letters. The most recent Statement of Deficiencies contained in the binders was from 2023. The facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents, family members, and legal representatives. The above information was reviewed with the Nursing Home Administrator on June 10, 2025, at 2:45 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify changes to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 1). This deficiency is cited as past noncompliance Findings include: A review of the facility policy titled, Skin Integrity and Wound Management, dated October 15, 2024, revealed that, a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin and wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revision to the plan of care as needed. Notify Medical Director, Director of Nursing, and Administrator, if deviation from protocol is requested by the physician, advanced practice provider, managed care company, or others. Review of the policy revealed a section titled, Practice Standards, that indicated the licensed nurse will evaluate any reported or suspected skin changes or wounds, perform and document skin inspection on all newly admitted and readmitted patients weekly thereafter, and with any significant change of condition; and complete a wound evaluation upon admission or readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Clinical record review for Resident 1 revealed a diagnoses list that included unspecified protein calorie malnutrition (when the body does not receive enough protein and calories to maintain a healthy status), Type 2 diabetes mellitus with chronic kidney disease (when the body does not properly use sugar that leads to high blood sugar levels that also negatively impacts the kidneys (two bodily organs that filter the blood), and generalized muscle weakness. Review of Resident 1's current care plan revealed the resident has cognitive loss as evidenced by a low BIMS (Brief Interview for Mental Status) and forgetfulness secondary to the resident's medical history. An attempted interview with the resident on April 15, 2025, at 2:55 PM revealed the resident was cognitively impaired and unable to complete the interview with the surveyor. A physician's order for Resident 1 dated February 3, 2025, instructed staff to perform a body audit with skin evaluation every Wednesday on evening shift. Further review of the physician orders for Resident 1 revealed current orders for wound cleaning and dressing change for a sacral (a bone at the base of the spine) wound to be completed daily. Nursing documentation for Resident 1 dated February 27, 2025, at 1:37 PM revealed that staff observed an open area to the sacrum, the wound was measured, and treatment initiated. The physician and responsible party were made aware. Wound care documentation by the facility wound care nurse dated February 27, 2025, noted moisture associated skin damage (MASD, damage to the skin caused by moisture) to the sacrum that measured 2.07 centimeters (cm) x 2.07 cm x 0.1 cm. Skin check documentation in the progress notes dated March 5, 2025, at 3:38 PM noted a new skin issue to the buttocks documented as MASD. The wound measurements were noted as not documented as part of this assessment, because the measurements were completed by wound nurse. There were no further assessments provided of the resident's wound (such as wound description, size, tissue status, indicators of infection, inflammation, etc.). Wound care documentation by the facility wound care nurse did not note any assessment for March 5, 2025, as indicated in the above skin check documentation. Wound care documentation for Resident 1 by the facility wound care nurse on March 12, 2025, measured the wound as 2.07 cm x 2.07 cm x 0.1 cm. A skilled nursing evaluation for Resident 1 dated March 18, 2025, at 11:48 AM revealed that there was MASD on the buttocks and measurements were not documented because the resident is being followed by wound nurse for MASD issues. There was no further assessment provided of the resident's sacral wound. A skilled evaluation for Resident 1 dated March 19, 2025, at 10:34 AM revealed that there was MASD on the buttocks and measurements were not documented because the resident is being followed by wound nurse. The staff made a skin note that indicated, .MASD to sacrum/buttocks and is followed by wound nurse for same. There was no further assessment provided of the resident's sacral wound. A skilled evaluation for Resident 1 dated March 20, 2025, at 11:55 AM revealed that there was MASD on the coccyx (tailbone) and measurements were not documented because the resident is being followed by wound nurse. The progress was documented as stalled. There was no further assessment provided of the resident's wound. Wound care documentation by the facility staff for Resident 1 dated March 21, 2025, revealed that the resident's wound now measured 5.34 cm x 3.77 cm x (no depth documented), which indicated a deterioration in the wound. Nursing documentation dated March 22, 2025, at 3:27 PM revealed the resident was sent to the emergency department for abnormal vital signs. The resident was admitted to the hospital for acute kidney injury. The resident returned to the facility from the hospital on March 25, 2025. Hospital physician documentation dated March 23, 2025, at 8:28 AM revealed the resident has a sacral ulcer on exam and per wound nurse, the resident only had a blanchable redness back in January and therefore current stage 2/3 ulcer is fairly new. Wound care consultation (a third party wound management service that is contracted by the facility to perform various wound care needs/treatments/assessments) dated March 26, 2025, noted an initial wound evaluation that indicated Resident 1 had a deep sacral pressure ulcer that is unstageable at this time due to slough covering most of the wound and a debridement (removal of damaged tissue) was completed. An interview with the Director of Nursing on April 15, 2025, at 12:29 PM revealed there should have been wound documentation from the wound care nurse between February 27, 2025, and March 12, 2025, and again on March 19, 2025. These assessments were not completed by the facility wound care nurse who was following Resident 1's wound. The next wound assessment on March 21, 2025, after the missed assessment by the facility wound care nurse on March 19, 2025, revealed a deterioration in Resident 1's wound. The facility failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify changes and promote healing of a pressure ulcer. The facility identified the issue with Resident 1's skin assessments on March 21, 2025, and as a result, disciplinary action was taken against Employee 1, licensed practical nurse, and a full house audit was conducted to identify any further residents impacted. The facility conducted staff education that included the following: Skin Integrity and Wound Management on March 21, 2025. Emergency Response and Preparedness; Abuse Prohibition; Skin Integrity; and Wound Management on March 27, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 15, 2025, at 3:15 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of seven residents reviewed, which resulted in actual harm (Resident 10). Findings include: Resident 10's clinical record revealed the resident had a diagnosis of Type 1 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) and a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar (dead tissue) may be present on some parts of the wound bed; often includes undermining and tunneling) Pressure Ulcer of the Sacral Region (low back) on admission to the facility on [DATE]. Review of a fax communication to the physician for Resident 10 dated July 30, 2023, revealed the nurse reported that the resident has a lump on his back between the shoulder blades that was approximately 6 cm (centimeter) in diameter. The top of the area was slightly firm, and the bottom was soft with a slight discoloration to the left of the area. The fax indicated that the RN (registered nurse) assessed and marked the area with a black Sharpie (marker) to monitor the size. The CRNP (clinical registered nurse practitioner) replied on July 31, 2023, to monitor-comfort measures only (comfort measures, no other intervention, or medications, which are not related to making the patient more comfortable). There was no documented evidence of the RN's assessment that corresponds with this fax. Review of an LPN progress note for Resident 10 dated July 31, 2023, at 6:42 AM revealed that the CRNP was on rounds and was aware of the resident refusing morning medications and aware of the lump on his back. Staff were to continue to monitor the area due to the resident being on comfort measures only. There was no documented evidence of the CRNP assessing Resident 10's lump on his back. Review of wound specialist reports for Resident 10 revealed that he had treatment and recommendations for the wounds on the sacrum (low back), and the right and left buttocks on August 1 and 9, 2023. The wound on the upper back was not mentioned. Clinical record review for Resident 10 revealed the next note for the upper back wound was from a wound specialist dated August 15, 2023. The wound of the left upper back was classified as pressure in etiology (cause), unstageable due to necrosis (an ulcer with full thickness tissue loss that is covered by dying tissue), the duration of greater than five days, that measured 4 cm width x 0.1 cm depth, the surface area was 16 cm, with an open ulceration area of 12 cm. The wound had light serous exudate (drainage), with 25 percent eschar and 25 percent granulation (new connective tissue) tissue. The left upper back wound was not debrided (surgical removal of dead tissue for optimal healing) by the specialist because the wound was so desiccated (dried out) that debridement could not accomplish anything meaningful until worked on by moisture donator (special moisture type dressing) for some time. The specialist ordered to cleanse the wound with saline (solution like normal body fluid), apply a hydrogel (a specialized wound healing dressing that also debrides or removes dead tissue) dressing, change daily, cover with an ABD (a large, padded dressing) pad, and gauze dressing with a border. Limit resident sitting to 60 minutes, off-load wound (no weight bearing on wound), and reposition per facility protocol. During a meeting with the Director of Nursing on August 16, 2023, at 1:45 PM the surveyor asked for additional information on Resident 10's unstageable pressure area of the left upper back specially questioning why a lump was identified when it possibly met the definition of a DTI (DTI, deep tissue injury is an unstageable pressure area either a Stage III, full thickness tissue loss, but bone, tendon, or muscle is not exposed, or Stage IV; as a result of an injury to the underlying tissue below the skin's surface from prolonged pressure in an area of a body). The surveyor also asked for RN or CRNP/physician assessments of the left back from when the area was discovered on July 30, 2023, and any prior to August 15, 2023, when it was evaluated by the wound specialist. There was no documented evidence of a full assessment of the upper back wound that identified it as blanchable (area of redness that disappears on applied pressure) or not blanchable (area of redness that does not disappear on applied pressure, indicative in determining a pressure area). The National Pressure Advisory Panel defines unstageable pressure injuries as a purple or maroon localized area or discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, or boggy, or warmer or cooler than adjacent tissue. Review of a late entry RN progress note for Resident 10 created on August 16, 2023, at 4:08 PM for August 11, 2023, at 4:01 PM revealed that the LPN asked the RN to assess the red lump on the resident's upper back. The RN assessed it as the beginning of skin breakdown. The area was cleansed, and protective foam was applied. The RN alerted the nursing staff and informed the wound doctor. The RN will have the resident physically seen by the wound doctor and will create a new treatment plan for the area. The RN repositioned the resident to the side to alleviate pressure on the area. The resident was educated on the importance of getting repositioned. Observation of the dressing change to Resident 10's upper back was performed by Employee 9, RN, on August 17, 2023, at 11:11 AM. The resident was repositioned by two staff for the dressing change. The dressing was saturated with serosanguineous (pink and tan in color) drainage. The upper back wound was to the left of the backbone and not between the shoulder blades as described in the fax communication to the CRNP on July 30, 2023. Immediately after the dressing change, the surveyor asked Employee 9 if skin alteration records were completed as the facility did not have pressure ulcer assessments for Resident 10 prior to August 15, 2023. Concurrent interview with Employee 9, revealed that skin alteration records are used by floor staff to monitor non-pressure related wounds and she uses them to monitor pressure wounds that are followed by the wound specialist. The forms were in Employee 9's office. The surveyor was provided with skin alteration records. Review of a skin alteration record completed by an LPN for Resident 10 dated July 30, 2023, revealed that a foam pad was placed on the red lump on the upper back. This skin alteration record had three columns for documentation. The first area was on the left of the page and dated August 7, 2023, and in the center of the page was the second area, which was dated July 30, 2023, and the third area was blank. The column dated August 7, 2023, indicated the dark pink/red tissue was present by checkmark and the foam was in place, and keep monitoring per CRNP. There was no corresponding physician order or documentation on the TAR, (TAR, treatment administration record) that a foam pad was applied. Further review of skin alteration records for Resident 10 revealed that on August 11, 2023, the upper back wound measured 5 cm x 5 cm and was without drainage. The resident had pain at the site. The form indicated the RN asked the wound specialist to see the resident on the next visit. There was no documented evidence of the need for nurse aides to reposition Resident 10 off his left upper back until recommended by the wound specialist on August 15, 2023. The facility's failure to initially assess and treat Resident 10's left upper back wound resulted in harm. The facility failed to fully assess the upper back lump on July 30, 2023, and failed to provide off-loading in which the area increased in size and worsened to an unstageable pressure ulcer on August 15, 2023. There was no documented evidence of an RN assessment (only a note by LPN that the RN assessed) until 11 days later when the RN determined the wound needed evaluation and treatment by a wound specialist. These issues were discussed with the Director of Nursing on August 17, 2023, at 1:45 PM. 483.25(b)(1)(i)(ii) Treatment/Svcs to Prevent/Heal Pressure Ulcers Previously cited 7/28/22 28. Pa. Code 211.12(d)(1)(2)(3) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent a resident accident, which resulted in serious injury (fractured left hip) for one of six residents reviewed (Resident 13). Findings include: The facility policy entitled, Falls Practice Guide, last reviewed without changes on November 28, 2016, indicated that fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. The center utilizes the APIE (Assess, Plan, Implement, and Evaluate) framework as a systematic method to identify risk, select interventions to reduce the risk, and monitor the effect on risk reduction. The comprehensive care plan approaches for fall interventions are clear, specific, and individualized for the patient's needs. Clinical record review for Resident 13 revealed nursing documentation dated August 13, 2017, at 10:05 AM indicating that at 10:00 AM, staff notified the registered nurse of Resident 13's fall. Resident 13 was seated on the floor. Resident 13 sustained a superficial abrasion on her back measuring 1.5 cm (centimeters) by 1.5 cm. Review of the facility's investigation of Resident 13's fall on August 13, 2017, revealed that the conclusions (interventions) developed by the facility to prevent recurrence of falls included to offer to walk with Resident 13 if the resident is becoming restless in her chair. Review of Resident 13's plan of care developed by the facility to address the resident falls dated July 2, 2017, revealed that staff added the intervention to take Resident 13 for a walk if the resident becomes restless in her chair on August 14, 2017. Nursing documentation dated August 15, 2017, at 5:20 PM revealed that staff called the registered nurse to assess Resident 13 because she had fallen. The licensed practical nurse reported that Resident 13 stood from her wheelchair in the hallway and fell forward landing on her right side with her head against the molding on the corner of the closet. Review of the facility's investigation of Resident 13's fall on August 15, 2017, revealed that the timeline of events indicated that Resident 13 was in the dining room for dinner at 4:30 PM and in her wheelchair at the nurse's station in the hallway at 5:00 PM. Information obtained during the investigation indicated that Resident 13 had become very agitated after supper, pushing away from the table and attempting to throw a dinner plate at a staff member. The investigation did not obtain any evidence to indicate that staff offered to walk with Resident 13 when they identified her agitation before her fall (as per her care planned intervention following her fall on August 13, 2017). The actions taken by the facility during the investigation to prevent recurrence of falls included to provide Resident 13 with a table with activities to keep her occupied when seated in the hallway instead of sitting in the hall with nothing to do. Review of Resident 13's plan of care developed by the facility to address her falls dated July 2, 2017, revealed that staff did not add the intervention to provide Resident 13 with activities to keep her occupied when she is sitting in the hallway for observation and safety until August 30, 2017. Nursing documentation dated August 18, 2017, at 7:45 PM revealed that staff called the registered nurse to the unit where she noted Resident 13 lying on the floor face down. Resident 13 sustained a contusion (bruise, collection of blood that seeped from blood vessels under the skin) above her right eye. Review of the facility's investigation of Resident 13's fall on August 18, 2017, indicated that at 7:30 PM staff noted Resident 13 sitting in the hall in her wheelchair. At 7:45 PM, staff noted Resident 13 stand, attempt to reach back to wheelchair to sit down, and fall forward onto the floor. The investigation did not indicate any evidence that staff provided activities to keep Resident 13 occupied while sitting in the hallway. Actions taken by the staff following Resident 13's fall included giving her a doll to play with while she was in the hallway for supervision. The investigation indicated that the new intervention implemented to prevent recurrence was, .when becoming restless in w/c (wheelchair) take resident for a walk . The investigation failed to identify that this intervention was already a part of Resident 13's plan of care as of August 14, 2017. Nursing documentation dated August 30, 2017, at 1:20 PM revealed that Resident 13 was seated in her wheelchair in the hallway and staff observed her stand from the wheelchair, take a few steps to her right, and fall with her right side against a room doorway with her legs flexed. Resident 13 complained of slight discomfort when she lifted her left leg, but had displayed this discomfort at times prior to the fall. Nursing documentation dated August 30, 2017, at 1:48 PM revealed that following the fall, staff took Resident 13 to the bathroom where they noted her to be incontinent of a small amount of urine and she also voided in the toilet at that time. Review of the facility's investigation into Resident 13's fall on August 30, 2017, at 1:20 PM revealed that the timeline of events indicated the following: 10:28 AM toileted in bathroom 11:15 AM - 1:00 PM in the dining room for lunch and socializing 1:00 PM - 1:20 PM in the hallway at the nurse's station in her wheelchair 1:20 PM stood up by herself and fell The information obtained during the investigation determined that staff did not toilet Resident 13 after lunch per her toileting schedule. The actions taken during the investigation to prevent fall recurrence included providing activities to keep Resident 13 busy when she was seated in the hallway. The investigation failed to identify that this intervention was appropriate for Resident 13 after her fall on August 15, 2017. The investigation did not obtain any evidence to indicate that staff provided activities to keep Resident 13 occupied while sitting in the hallway at the time of her fall. Review of Resident 13's plan of care to address her urinary and bowel incontinence (initiated August 1, 2017) confirmed that interventions included toileting after meals. Nursing documentation dated September 1, 2017, at 12:32 PM revealed that staff reported Resident 13 complained of severe pain in her lower back and hips when they transferred her back to bed after lunch. Nursing documentation dated September 1, 2017, at 6:21 PM revealed that staff obtained a physician's orders [REDACTED]. An X-ray report dated September 1, 2017, concluded that the study results were suspicious of a minimally displaced fracture of the sub capital left femoral neck (left hip fracture). Nursing documentation dated September 2, 2017, at 12:35 AM revealed that staff received the X-ray report and obtained a physician's orders [REDACTED]. Nursing documentation dated September 2, 2017, at 1:03 PM revealed that the emergency room nurse informed the staff that Resident 13 was admitted with the [DIAGNOSES REDACTED]. Interview with the Director of Nursing on September 18, 2017, at 2:00 PM reviewed the findings above. The interview confirmed that the facility had no further evidence that staff implemented interventions included in Resident 13's plan of care to prevent recurrent falls resulting in a hip fracture. 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/supervision/devices Previously cited deficiency 1/6/17, 2/5/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 1/6/17, 9/6/16, 7/27/16, 2/5/16

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to assess and implement interventions to prevent skin breakdown for one of 23 sampled residents (Resident 76). Findings include: Interview with the Director of Nursing on February 14, 2014, at 12:30 PM revealed that the facility could provide only a "Skin Practice Guide Process Flowchart," as the only procedure followed to determine a resident's risk for, and the facility's treatment of [REDACTED]. Review of the "Skin Practice Guide Process Flowchart," revealed that after assessment of whether a resident has a skin alteration or not, the facility will, "Plan." The flowchart did not define what, "Plan," meant; however, the following step is to develop/revise the initial or interdisciplinary care plan as applicable and, "Implement." The flowchart did not provide any definitions as to what, "Implement," entails. The flowchart also did not delineate the staff responsible to complete each step of the flowchart. Clinical record review for Resident 76 revealed that the facility admitted him on October 18, 2013, with [DIAGNOSES REDACTED]. Nursing documentation dated October 18, 2013, at 5:15 PM noted no alteration to his skin integrity; however, Resident 76 had bilateral lower extremity [MEDICAL CONDITION] (swelling often indicative of compromised circulation to the lower extremities increasing his risk for skin breakdown). A plan of care created on October 18, 2013, identified that Resident 76 was at risk for alteration in skin integrity related to his impaired mobility and diabetes. Interventions to address this risk included the nurse aides and nurses observing his skin condition with care daily and reporting abnormalities. Interview with the Director of Nursing and the Nursing Home Administrator on February 12, 2014, at 2:00 PM, February 13, 2014, at 1:00 PM, and February 14, 2014, at 10:45 AM, revealed that the facility had no documented evidence substantiating that the nurse aides and/or licensed nursing staff assessed the skin integrity of Resident 76's bilateral lower extremities (including feet) daily. Nursing documentation dated November 7, 2013, at 3:32 PM revealed that therapy staff reported noting bilateral heel wounds; left heel with 6 cm (centimeters) by 5.5 cm area of moveable light brown eschar (leathery slough, piece of dead tissue resulting from prolonged pressure over the bony prominence of the heel) and the right heel with 4.75 cm by 5.75 cm area of moveable light brown eschar. Resident 76 reported pain at the wound sites that varied depending on the pressure applied. Nursing staff obtained a treatment for [REDACTED]. Interview with Employee 11, registered nurse/wound care nurse, on February 13, 2014, at 11:20 AM confirmed that the facility had no evidence of nursing staff identifying the initial symptoms of pressure ulcer development (bogginess, redness, or other discoloration, tenderness, etc.) to Resident 76's bilateral heels prior to the therapy staff's discovery of the eschar on November 7, 2013. Employee 11 also confirmed that she completed the documentation of the bilateral heels measurements on the form entitled, "Skin Alteration Record, Do Not Use for Pressure Ulcers," although the sites were over the bony prominences of the heels (common site for pressure ulcers). Employee 11 was unable to provide the assessed measurements of Resident 76's left heel after January 7, 2014 (2.5 cm by 1.8 cm at that time); and measurements of Resident 76's right heel for January 21 and 28, 2014, and February 11, 2014 (last measured as 4 cm by 2.1 cm on February 4, 2014). Observation of Resident 76 on February 12, 2014, at 10:00 AM confirmed he had black eschar over the bony prominences of his bilateral heels approximately the size of a half-dollar. 201.18 (b)(1)(d) Management. 211.10 (a)(d) Resident care policies. Previously cited 1/11/13. 211.11 (a) Resident care plan. 211.12 (d)(1) Nursing services. Previously cited 1/11/13. 211.12 (d)(2)(5) Nursing services. Previously cited 1/11/13 and 9/20/13.

Based on clinical record review, review of select facility policy and procedures, review of fall investigations, and staff interviews, it was determined that the facility failed to implement interventions to prevent accidents for one of 23 residents sampled (Resident 91). Findings include: The "Falls Practice Guide Flowchart," reviewed January 14, 2014, does not provide an explanation or guidance in how nursing staff should initiate appropriate and individualized interventions for a resident experiencing falls. Review of Resident 91's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated October 31, 2013, indicating that nursing staff assessed her as needing the extensive assistance of two staff members to transfer. Resident 91 also has a [DIAGNOSES REDACTED]. Review of Resident 91's clinical record revealed nursing documentation dated December 3, 2013, at 3:32 PM indicating that Resident 91 transferred herself to the bathroom. Nursing staff documented that they provided instruction to Resident 91 to use her call bell for assistance. Nursing documentation dated December 13, 2013, at 10:57 PM indicated that Resident 91 was reaching for her privacy curtains and fell . Again, the facility educated Resident 91 to use her call bell to get assistance from staff. Nursing staff placed a sign in Resident 91's room indicating that she needs to use her call bell for assistance. Nursing staff indicated that Resident 91 has a reacher but will not use it, and also does not ring her call bell. Nursing documentation dated December 14, 2013, at 2:11 PM indicated that nursing staff found Resident 91 in the bathroom. Nursing staff again instructed Resident 91 to use her call bell for assistance. Nursing documentation dated December 15, 2013, at 2:14 PM indicated that nursing staff again found Resident 91 in the bathroom. Nursing staff again educated Resident 91 to ring her call bell for assistance. Nursing documentation dated December 15, 2013, at 3:33 PM indicated that Resident 91 fell reaching for a blanket. Nursing staff again educated Resident 91 to use her call bell for assistance and reminded her about the sign to use the call bell. The facility placed Resident 91 on 15 minute checks at this time, but only did so for the remainder of the second shift. Nursing documentation dated December 18, 2013, at 7:30 PM indicated that nursing staff found Resident 91 on the floor in front of her sink. Resident 91 indicated that she was brushing her teeth with her knee propped against the sink. The facility transferred Resident 91 to the hospital with a fractured femur. Interview with the Director of Nursing on February 14, 2014, at 11:50 AM confirmed the above findings. The facility failed to identify that the reeducation of Resident 91 to use her call bell was an ineffective intervention (there was no indication that Resident 91 was able to retain this direction) to prevent accidents and failed to implement additional interventions to prevent further accidents. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 1/11/13 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/11/13 and 9/20/13

Based on select facility guidelines, clinical record review, and staff interview, it was determined that the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for one of 24 sampled residents (Resident 2). Findings include: The "Hydration Management" guideline, last reviewed by the facility on July 13, 2009, revealed that staff would provide an ongoing evaluation for physical symptoms of dehydration. Staff would also provide an ongoing evaluation of resident response to interventions to prevent dehydration. Clinical record review for Resident 2 revealed [DIAGNOSES REDACTED]. Staff admitted Resident 2 to the facility on [DATE]. Review of a "Nutrition Risk Assessment" (an assessment of the resident identifying nutritional and fluid needs) dated July 15, 2010 revealed that Resident 2's fluid needs were 2425 - 2910 cc (cubic centimeters) of fluid each day. Laboratory results completed on July 27, 2010, indicated a BUN level (blood urea nitrogen) of 16 milligram/deciliter (mg/dl), (normal 6-20 mg/dl), and a Creatinine level of 0.72 mg/dl (normal 0.5-1.2 mg/dl). Laboratory tests that indicate hydration status include BUN and Creatinine. Elevated levels indicate dehydration. Review of Resident 2's plan of care revealed that staff should monitor Resident 2's skin, labs (laboratory values), and hydration status. Staff initiated these measures on August 9, 2010. A Dehydration/Fluid Maintenance assessment dated [DATE], identified factors that Resident 2 displayed that may impede her ability to maintain fluid balance. These factors included a comprehension/communication problem, moderate/severely impaired decision-making ability, and decline in cognitive status. Review of meal completion percentages from July 1-31, 2010, revealed that Resident 2 ate 75-100 percent of her meals 64 percent of the time. Meal completion percentages from August 1-31, 2010, revealed that Resident 2 ate 75-100 percent of her meals 35 percent of the time, 50 percent of her meals 26 percent of the time, and 0 to 25 percent of her meals 34 percent of the time. Resident 2 refused two percent of her meals. Resident 2's meal completion percentages from September 1-30, 2010, revealed that Resident 2 ate 75-100 percent of her meals 27 percent of the time, 50 percent of her meals 21 percent of the time, and 0 to 25 percent of her meals 44 percent of the time. Resident 2 refused six percent of her meals. laboratory results dated [DATE], revealed that Resident 2's BUN level was now elevated to 37 mg/dl. Review of a "Fluid Maintenance" assessment dated [DATE], revealed that staff identified that Resident 2 had an abnormal BUN level. Staff also identified other factors, which could cause Resident 2 to have difficulty with maintaining her fluid status. This included dementia, depression, difficulty making self-understood, and difficulty understanding others. Staff identified that Resident 2 had sustained weight loss, skips meals or consumes less than 25 percent of her meals, and is dependent on staff for fluid intake. On October 14, 2010, staff changed Resident 2's diet from regular to full liquids. Review of meal completion percentages from October 1-31, 2010, revealed that Resident 2 ate 75-100 percent of her meals 15 percent of the time, 50 percent of her meals 26 percent of the time, and 0 to 25 percent of her meals 34 percent of the time. Resident 2 refused eight percent of her meals. Meal completion percentages from November 1-30, 2010, revealed that Resident 2 ate 75-100 percent of her meals 23 percent of the time, 50 percent of her meals 20 percent of the time, and 0 to 25 percent of her meals 53 percent of the time. Resident 1 refused eight percent of her meals. Nursing documentation dated December 4, 2010 at 7:00 AM, revealed that staff thought that Resident 2 felt warm. Resident 2's temperature was 100.2 degrees Fahrenheit, her pulse rate was 109 beats per minute, her respiratory rate was 23 breaths per minute, and her blood pressure was 92 over 50 mm/hg (millimeters of mercury). Staff transferred Resident 2 to the hospital emergency room . Review of laboratory results dated [DATE], revealed that Resident 2's BUN level was significantly elevated to 97 mg/dl and her Creatinine was 1.98 mg/dl upon admission to the hospital. The hospital discharge summary dated December 9, 2010, revealed that Resident 2 was admitted to the hospital with [REDACTED]. Staff at the hospital provided Resident 2 with IV (intravenous - fluids provided via a catheter into the blood stream) fluids. Review of laboratory results dated [DATE], revealed that Resident 2's BUN level was back to the normal range of 16 mg/dl and her Creatinine was normal at 0.69 mg/dl. Staff transferred Resident 2 from the hospital back to the facility on [DATE]. Clinical record review revealed no documentation that staff monitored Resident 2's Intake/Output (I&O - documentation of the actual amounts of fluids taken in and urine excreted). The clinical record revealed no documentation that staff was monitoring Resident 2 for signs or symptoms of dehydration. The facility was unable to provide documentation that staff monitored Resident 2's actual fluid intake or her physical condition for signs of dehydration, despite assessments that identified Resident 2 had conditions, which may lead to dehydration. Resident 2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, there is no indication if Resident 2 accepted these fluids or what percentage of these fluids she might have consumed. Interview with Employee 1 (registered dietitian) on January 7, 2011, at 12:30 PM, revealed that Resident 2's meal completion rate from November 1, 2010 to December 4, 2010 was an average of 28 percent. Employee 1 revealed that the Resident 2's average fluid intake from meals for that time was 571 cc. Employee 1 indicated that staff documented that Resident 2 also received 240 cc from ice cream and 360 cc from shakes each day. Review of Resident 2's November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility was unable to provide documentation that Resident 2 received ice cream at any other time. Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1, on January 7, 2011, at 12:30 PM, confirmed that staff did not complete I&Os for Resident 2. The Director of Nursing and Employee 1 felt that Resident 2 was a "good drinker," but had no documentation to indicate the amount of fluids that Resident 2 actually consumed. The facility was unable to provide documentation that indicated that Resident 2 drank fluids well. The facility provided documentation, which Employee 1 confirmed, that Resident 2 only had an average of 28 percent completion of her full liquid diet. The facility was unable to provide any further documentation of Resident 2's fluid intakes. The facility failed to assess Resident 2 and implement interventions to ensure adequate hydration. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited deficiency 2/26/09.