Every finding on record at Thornwald Home

Based on observations, clinical record review, review of call bell audit reports, and resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing was provided to meet resident needs, as evidenced by extended call bell wait times, for four of 13 residents reviewed (Residents 4, 10, 11, and 12).Findings include: During an interview with Resident 13 on July 7, 2026, at 10:31 AM, she stated that she had concerns with call bell wait times, especially for her roommate, Resident 10. She stated that the prior day her roommate had to wait 45 minutes to be assisted to the bathroom. Review of call bell audit reports confirmed that Resident 10's call light was illuminated for 45 minutes and 12 seconds on July 6, 2026. Review of Resident 10's care plan dated June 29, 2026, revealed that she required a two-person assist to use the bathroom. Further review of Resident 10's call bell audit report revealed one additional time in the time period of June 30, 2026, through July 7, 2026, that her call light was on for 48 minutes. During an interview with Resident 4 on July 7, 2026, at 10:35 AM, she expressed concern with call bell wait times. Review of Resident 4's call bell audit report for the time period of June 30, 2026, through July 7, 2026, revealed three times where her call bell was on for greater than 30 minutes. Review of Resident 11's clinical record revealed diagnoses including Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels and acts). Review of Resident 11's physician orders revealed she was admitted to hospice services (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) on April 7, 2025, for Parkinson's Disease. Review of Resident 11's care guide revealed that she required assistance with toileting, and that she was to be kept clean and dry as possible to minimize skin exposure to moisture. Observation on July 7, 2026, at 10:46 AM, revealed that Resident 11's and 12's call light was already on and illuminated in the hallway. Observation at 10:53 AM revealed Employee 2 (Nurse Aide) telling the nurse that she was leaving for break. Resident 11's call light remained illuminated at that time. During an interview with Resident 12 (Resident 11's spouse) on July 7, 2026, at 11:06 AM, he revealed that the call light had been on for a while and that his wife was cold and wet and needed to be cleaned up. He stated that no one had been in to check to see what was needed. An immediate interview with Resident 11 confirmed that this was correct. Observation of Resident 11 revealed she was in bed with a blanket over her lap, with her legs exposed from the knees down. Observation at 11:27 AM revealed Employee 3 (Licensed Practical Nurse) entered Resident 11's room, turned off the call light and stated she would find help. Observation at 11:30 AM revealed Employee 2 and Employee 4 (Nurse Aide) returned to Resident 11's unit. Observation at 11:31 AM revealed Employee 4 entered Resident 11's room to provide care. Review of Resident 11's call bell audit report revealed that the total call bell wait time for the aforementioned observation was 93 minutes. Review of Resident 11's call bell audit report for the timeframe of June 30, 2026, through July 7, 2026, revealed 13 additional times that the call bell was on for greater than 30 minutes (with the longest wait time being 104 minutes). Review of Resident 12's call bell audit report for the timeframe of June 30, 2026, through July 7, 2026, revealed that he illuminated his call bell twice during that time, and that both wait times exceeded 60 minutes. During a later interview with Residents 11 and 12 on July 7, 2026, at 12:45 PM, they both confirmed that long call bell wait times occur a lot. During an interview with the Nursing Home Administrator on July 7, 2026, at 1:37 PM, she revealed that expectation that residents receive timely care. She also revealed that they were already in the process of interviewing and re-educating staff related to the incident with Resident 11. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 18 residents reviewed (Residents 4, 12, and 14). Findings include: Review of policy titled Bed Entrapment Prevention Program, revised November 11, 2022, read, in part, monitoring of resident's health status that may affect the risk of bed entrapment will be done periodically (at least quarterly) to assess resident continued need for the device and document in the electronic medical record. Review of facility policy, titled Trauma Informed Care, revised October 2024, read, in part, trauma informed care shall be an integral part of a person-centered environment. This involves an interdisciplinary approach to care. Ensuring care and services are person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. Review of Resident 4's clinical record revealed diagnoses that included Parkinson's disease (progressive movement disorder of the nervous system) and weakness (decrease or loss of muscle strength). During an interview with Resident 4 on December 8, 2025, at 10:32 AM, an observation of a right sided enabler bar was made. Resident 4 reported he used the bar to help him move while in bed. Review of Resident 4's physician orders revealed an order for right side bed enablers. Review of Resident 4's quarterly minimum data sets (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated August 18, 2025, and October 28, 2025, revealed Resident 4 was coded for restraint use related to enabler bars. An interview with the Nursing Home Administrator (NHA) on December 9, 2025, at 11:15 AM, revealed that Resident 4's MDSs had been coded incorrectly, and a modification would be done to correct them. During an additional interview with the NHA on December 10, 2025, at 10:35 AM, the NHA stated that it was the expectation of the facility that MDSs accurately reflect the Resident's status. Review of Resident 12's clinical record revealed diagnoses that included adjustment disorder with mixed anxiety and depressed mood. Interview with Resident 12 on December 8, 2025, at 11:50 AM, revealed that she had lost her son a year ago, and that was something she would never get over. Resident 12's care plan included a focus area for trauma informed care. The care plan indicated that Resident 12 witnessed someone choke and the heimlich was not successful. Resident chooses not to go to the dining room due to this experience, and services for counseling as indicated. Per Psychology consults dated September 22nd, 2025, and November 10th, 2025, it was documented that 50 percent of the session was related to grief/loss. Review of Resident 12's quarterly MDS dated [DATE], section I (diagnoses) failed to document PTSD (post-traumatic stress disorder - a mental health condition triggered by experiencing or witnessing a traumatic event). Interview with NHA on December 9, 2025, at 11:15 AM, it was revealed that Resident 12's November 7th, 2025, MDS should've documented PTSD and that the CMS form 802 (Matrix) was updated to include the PTSD/trauma informed care designation. Review of Resident 14's clinical record documented diagnoses that included hemiplegia (paralysis or severe weakness affecting one side of the body). Observation in Resident 14's room on December 10, 2025, at 11:30 AM, revealed an enabler bar was on the right side of the bed. Resident 14's physician orders included a right-side enabler for bed mobility and increased independence, start date August 14, 2025. Resident 14's quarterly MDS dated [DATE], revealed Resident 14's MDS was coded for restraint use related to enabler bars. Interview with NHA on December 9, 2025, at 11:30 AM, revealed that Resident 14's September 12th, 2025, MDS had been coded incorrectly, and a modification would be done to correct it. 28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to verify the standing of professional license prior to hire for two of five personnel files reviewed (Employees 3 and 4). Findings Include:Review of facility policy, titled Admin Freedom from Abuse Policy, read, in part: I. Screening A. To ensure resident safety, UCC Homes will not hire prospective employees with disciplinary action against their licenses or certification, which includes Individuals found guilty of abuse. Prospective employees will undergo screening within the allowable timeframes. The screening process shall include: Verification of active Licensure or Certification with the Department of State and the original display portion of licenses on file, if appliable. Verification of enrollment in Department of State registry, if applicable.Review of the personnel file for Employee 3 (Certified Nursing Assistant [CNA]), revealed Employee 3's nursing assistant certification was verified on December 9, 2025, indicating certification verification was not completed prior to Employee 3's date of hire on September 10, 2025. Review of the personnel file for Employee 4 (Licensed Practical Nurse [LPN]), revealed license verification with the Pennsylvania licensing board was completed on December 9, 2025, indicating license verification was not completed prior to Employee 4's date of hire on November 19, 2025. During an interview with the Nursing Home Administration on December 11, 2025 at 8:30 AM, it was revealed that Human Resources completes a check list to ensure all items are completed, to include verification of license, and the information is forwarded to the hiring manager. The hiring manager discards the information that is not entered into the employee's file. They were unable to locate verification of licensure verification completed prior to the hire dates for Employee 3 and Employee 4. 28 Pa Code 201.18(e)(1)(2) Management28 Pa Code 201.19 Personnel policy and procedures

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident 10).Findings include: Review of facility policy, titled Wound Management Program Infection Prevention and Control, dated February 2018, revealed, in part, Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal for a resident with a wound is one of promoting healing and preventing infection unless their preference and medical condition necessitate palliative care as the primary focus. Our facility's commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, evidence clinical guidelines, and interdisciplinary involvement. Review of facility policy, titled Skin Integrity Program: Pressure Ulcer Prevention/Treatment Program, dated April 27, 2023, revealed, in part, Based on a comprehensive assessment, the facility shall ensure that a resident who enters the facility without a pressure ulcer does not develop pressure ulcers unless the clinical condition demonstrates that they were unavoidable or if a pressure ulcer is present (e.g. time of admission) receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Revision of the interdisciplinary plan of care shall be based on the effectiveness of the interventions. Review of Resident 10's clinical record revealed diagnoses that included pressure ulcers (area of damaged skin and tissue caused by sustained pressure which reduces blood flow to the area) on the right heel, right buttock, and left heel; type II diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but may not require the use of insulin); and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Observations of Resident 10 on December 8, 2025, at 11:45 AM, and December 9, 2025, at 12:25 PM, revealed that he was up in his wheelchair in his room. He was noted to have an air overlay mattress on his bed, but the pump was off. Observation of Resident 10's room on December 10, 2025, at 1:53 PM, revealed that his air overlay mattress pump was off. Observation of Resident 10 on December 11, 2025, at 8:38 AM, with Employee 1 (Registered Nurse) and Employee 2 (Assistant Director of Nursing) revealed the Resident was in bed. The air overlay mattress pump was turned off and the connecting air hose on the overlay mattress was not connected to the pump. The connecting hose was noted to be on the floor at the foot of the bed. In addition, the pump was set to the setting for a Resident weight of 300 pounds. Employee 1 attempted to connect the hose to the pump, but the hose would not remain latched because the securing clip was broken off. Employee 2 pressed the power switch, but the pump did not come on. Employee 2 then checked to see of the cord was plugged in to the power source. Employee 2 indicated it was plugged in. Surveyor pressed the power switch, and the pump came on and then shut off. Employee 2 again checked the cord, and the pump came on and stayed on. Employee 2 indicated that she would contact maintenance to evaluate the electrical outlet and the air overlay mattress. Review of Resident 10's clinical record revealed that he weighed 159.2 pounds on December 1, 2025. Review of Resident 10's physician orders revealed an order for wound consult services for skin/wound conditions/prevention as needed, dated August 12, 2025. Review of Resident 10's clinical record revealed that he had been seen weekly by the wound consultant weekly since October 1, 2025. Further review of Resident 10's clinical record revealed the following:1) the pressure ulcer to his right heel developed at the facility on September 22, 2025, and was currently classified as a unstageable (pressure ulcer where depth cannot be determined due to presence of necrotic tissue called eschar); 2) the pressure ulcer to his right buttock developed at the facility on October 31, 2205, and was currently classified as an unstageable; and3) the pressure ulcer to his left heel developed at the facility on November 4, 2025, and was currently classified as a Stage 3 (pressure ulcer characterized by full-thickness skin loss, exposing the fatty tissue beneath, and may present with slough-a moist yellowish colored dead tissue- or eschar, but does not expose bone or muscle). Review of Resident 10's wound consult note dated November 5, 2025, revealed that Resident 10 had developed two new pressure ulcers and indicated in the Assessment/Plan section of the note that he would benefit from an air mattress for additional pressure relief. Review of Resident 10's wound consult note dated November 12, 2025, revealed that the unstageable right heel ulcer was worsening; the right buttock unstageable ulcer was stable; and the left heel Stage 3 was stable. The Assessment/Plan section of the note again indicated would benefit from an air mattress for additional pressure relief. Review of Resident 10's wound consult note dated November 19, 2025, revealed that the unstageable right heel ulcer was improving without complications; the right buttock unstageable wound was stable; and the left heel stage 3 was worsening. The Assessment/Plan section of the note again indicated would benefit from an air mattress for additional pressure relief. Review of Resident 10's wound consult note dated November 26, 2025, revealed that the unstageable right heel ulcer was improving without complications; the right buttock unstageable wound was now classified as a Stage 3 and was stable; and the left heel stage 3 was stable. The Assessment/Plan section of the note again indicated would benefit from an air mattress for additional pressure relief. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on December 10, 2025, at 3:05 PM, the NHA indicated that the air overlay mattress was placed on Resident 10's bed on November 21, 2025. Further review of Resident 10's clinical record failed to reveal a physician's order for an air overlay mattress or any documentation to support that the air overlay mattress was in place and the function/settings were being monitored between November 21, 2025, and December 10, 2025. During a staff interview with the NHA and Employee 2 on December 11, 2025, at 11:10 AM, Employee 2 indicated that maintenance had located the broken piece to the air hose under Resident 10's bed. She further indicated that maintenance replaced the air overlay mattress. The NHA confirmed that the pump should have been set for Resident 10's weight and that there were no orders prior today in place for staff to monitor the functioning or setting of Resident 10's air overlay mattress. The NHA confirmed that these measures should have been implemented when the air overlay mattress was initially placed on Resident 10's bed. She also added that they implemented education with staff about adding the monitoring of the air mattresses when they are ordered. During a staff interview with the NHA, DON, and Employee 2 on December 11, 2025, at 1:12 PM, the DON indicated that she had no documentation to provide to show why there was a three-week delay in applying the recommended air mattress on Resident 10's bed. She further indicated that she recalls that the interdisciplinary team had discussed Resident 10 in meetings in regard to the concern for the use of the air mattress and his high fall risk but could not provide supporting documentation of such. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations, facility documentation, and staff interviews, it was determined that the facility failed to conduct regular inspection of all bed rails/enabler bars as part of a regular maintenance program to identify areas of possible entrapment for one of two residents reviewed with enabler bars (Resident 14). Findings include: Review of Resident 14's clinical record documented diagnoses that included hemiplegia (paralysis or severe weakness affecting one side of the body). Observation in Resident 14's room on December 10, 2025, at 11:30 AM, revealed an enabler bar was on the right side of the bed. Resident 14's physician orders included a right-side enabler for bed mobility and increased independence, start date August 14, 2025. Review of Resident 14's enabler bar assessment and consent for use of the enabler bar were signed August 14, 2025. Review of maintenance record for Resident 14's enabler bar (safety measurements) was dated April 10, 2025. Interview with the Nursing Home Administrator (NHA) on December 10, 2025, at 1:13 PM, it was revealed that assessment for use of enabler bars should be completed at minimum quarterly with the Minimum Data Set review (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) and the safety measurements are completed annually. Per Director Of Nursing on December 10, 2025, at 2:00 PM, it was revealed that Resident 14 had enablers placed on her bed in April 2025, and she requested they be removed due to not being able to see the cats, so they were removed. Then the Resident asked for the enablers to be placed back on her bed in August 2025. During an interview with the NHA on December 11, 2025, at 10:20 AM, it was revealed the enabler bars weren't measured when they were placed back on the bed in August 2025, and measurements should've been completed at that time. 28 Pa. Code 201.18 Management 28 Pa. Code 205.71 Bed and furnishing

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a 10 cm (centimeter) x 8 cm x 1 cm laceration (a deep cut or tear in the skin) to the right leg, requiring 15 sutures (stitches), for one of seven residents reviewed (Resident 1). Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm as evidenced by a 10 cm (centimeter) x 8 cm x 1 cm laceration (a deep cut or tear in the skin) to the right leg, requiring 15 stitches, for one of seven residents reviewed (Resident 1). Findings include:Review of facility policy, titled No Lift Program, dated June 22, 2018, revealed The staff will do NO transfer, repositioning, or lifting without the aid of required and provided equipment.During an interview with the Nursing Home Administrator (NHA) on July 21, 2025, at 11:43 AM, she stated that all facility lifts require the assistance of two staff members. Review of Resident 1's clinical record revealed diagnoses that included stroke and hypertension (high blood pressure). Review of Resident 1's care plan revealed an intervention, dated March 24, 2025, to transfer with staff assist of two using stand aid. Review of Resident 1's Resident Care Guide, revealed an intervention on March 24, 2025, for two assist with stand aid for all transfers. Review of Resident 1's physical therapy Discharge summary, dated [DATE], revealed discharge recommendations for staff to use the stand aid lift with two person assist for transfers.Review of Resident 1's nursing progress notes revealed a note on July 4, 2025, stating that Resident 1 sustained a laceration (a deep cut or tear in the skin) to her right lower lateral (to the side of) leg during a transfer from her wheelchair to her bed at 6:10 PM. Upon assessment, the laceration was noted to be bleeding and measured 10 cm x 8 cm x 1 cm, with fatty layer exposed. Resident was transferred to the hospital for further treatment at 7:20 PM. Review of Resident 1's clinical record revealed that Resident 1 returned to the facility on July 4, 2025, at approximately 10:50 PM. Further review revealed that she received 15 sutures (stitches) to her right lower extremity laceration. Review of Resident 1's incident report, dated July 4, 2025, revealed that Employee 1 (Nurse Aide) assisted Resident 1 to bed, by herself, using a stand pivot from wheelchair. Further review of the incident report revealed that Employee 1 did not follow Resident 1's care plan for the transfer, which stated to use the stand aid with two assists. Review of facility's investigation revealed a statement from Employee 1, dated July 7, 2025. In the statement, Employee 1 stated that she transferred Resident 1 from her wheelchair to her bed, with a one assist stand pivot. After the transfer, Employee 1 noted that Resident 1 was bleeding, and she notified the supervisor. Further review of Employee 1's statement revealed that Employee 1 looked at Resident 1's care guide and saw she was a one assist for toileting. Employee 1 stated she was unaware of the need to scroll further on the care guide and failed to see that Resident 1 required the assist of two with a stand aid for transfers. During an interview with the NHA on July 21, 2025, at 2:42 PM, she stated that it is her expectation that staff follow a resident's correct transfer status. The facility failed to ensure that Resident 1 received adequate supervision and assistance to prevent accidents. Employee 1 failed to follow Resident 1's care planned transfer status and transferred Resident 1 via stand pivot, by herself. This resulted in a laceration to Resident 1's leg, requiring 15 sutures. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on personnel training file review, facility policy review, and staff interview, it was determined that the facility failed to implement written policies and procedures by not completing annual abuse training for one of three personnel training records reviewed (Employee 2). Findings include: Review of facility policy, titled Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property, dated February 9, 2023, revealed Employees, including those who work in the facility as consultants and volunteers will be educated upon hire during New Employee Orientation, Online Training Programs, and/or Information packets. Education will be provided annually and as needed; Covered individuals will receive training and education regarding the following: Identifying what constitutes abuse, neglect, exploitation, and misappropriate of resident property; Prohibiting and preventing all forms of abuse, neglect, misappropriate of property and exploitation; Recognizing signs of abuse, neglect, exploitation, and misappropriate of resident property; Reporting abuse, neglect, exploitation and misappropriate of resident property, including injuries of unknown sources and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. The policy further indicated that an Initial/Annual Acknowledgement (UCCH #1411) is provided to those vendors and contractors who do business with United Church of Christ Homes. Review of training transcript provided by facility for Employee 2 (a contracted Physician Assistant) revealed that the Employee had not received annual abuse training in the calendar year of 2024. During a staff interview with the Nursing Home Administrator (NHA) and Employee 2 (Assistant Director of Nursing) on January 30, 2025, at 3:32 PM, the NHA confirmed that there was no documentation of annual abuse to provide for Employee 2 or an annual acknowledgement as indicated in the facility policy. She confirmed that she would expect all staff, including contracted staff, to receive this training on an annual basis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.20(a)(5)(d) Staff development 28 Pa. Code 201.29(a) Resident rights

Based on facility policy review, clinical record reviews, facility documentation review, and staff interviews, it was determined that the facility failed to report an allegation of abuse in a timely manner for one of four residents reviewed (Resident 1). Findings include: Review of facility policy, titled Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property, dated February 9, 2023, revealed, in part, Any incident of abuse must be reported to the Executive Director/Designee; All reports of alleged abuse/neglect shall be immediately and thoroughly investigated. The immediate response shall consist of: Social Services/Designee to interview the resident and if possible, obtain a signed statement from the resident. Interview with the person(s) reporting the alleged abuse/neglect and obtain a signed statement, if possible. Interview and obtain signed statements, if possible, from any witness or individual who has knowledge of the alleged incident. If any allegation of physical abuse is made, the nurse shall examine the resident. Findings of the examination must be recorded in the resident's medical record. Investigation of alleged sexual abuse requires a physical exam by a physician, unless the resident or resident representative expressly refuses. Review of Resident 1's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), chronic combined systolic diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1's clinical record revealed a physician progress note written by Employee 2 dated January 9, 2025, at 10:28 AM, that indicated they had visited with Resident 1 this date and that she reported being assaulted in her genitalia. Specifically, she reported someone was cutting her in that area. She genuinely believes that these events occurred. The note further indicated, I did later talk to her nurse, who reviewed prior nursing notes with me. The note indicated that Resident 1 was alert and oriented to person and time, and that Employee 2 believed Resident 1's thought content was delusional. The documentation of their physical assessment failed to include any documentation that an assessment of Resident 1's genitalia was completed because of their reported assault. Review of Resident 1's clinical record revealed a physician progress note written by Employee 2 dated January 14, 2025, at 9:52 AM, that indicated they had visited with Resident 1 this date to follow-up on their delusions. The note indicated that Employee 2 had spoken to Resident 1's nurse who described her mental state as improving and that, as Employee 2 continued the conversation with Resident 1, she started to tell me again about being struck over the head, being assaulted in her genitalia, and being conspired against by staff. The note also indicated that Resident 1 was oriented to herself, and her thought content was delusional. The documentation of their physical assessment failed to include any documentation that an assessment of Resident 1 was completed because of their reported assault. Review of a facility provided witness statement written by Employee 6 (a Licensed Practical Nurse) dated January 30, 2025, revealed that on January 9, 2025, at approximately 8:20 AM, Employee 2 had approached them and was questioning them about Resident 1's delusions and accusations. The statement further indicated that Employee 6 did not recall any specific comments regarding any 'assault towards genitalia'. Employee 6 said that they discussed side effects of medications, signs and symptoms of acute gastrointestinal illness, and possible side effects of dehydration that could be causing Resident 1 to experience delusions and confusion. During an interview with Employee 1 (Assistant Director of Nursing) on January 30, 2025, at approximately 10:55 AM, Employee 1 indicated that on January 22, 2025, at 10:30 AM, while reviewing the Physician Assistant's (PA-Employee 2) progress notes that morning in clinical meeting it was discovered that Employee 2 had documented that Resident 1 had been assaulted in her genitalia in a January 9, 2025, and January 14, 2025, progress notes. Employee 1 indicated that an investigation was initiated immediately when this was discovered. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 on January 30, 2025, at 3:32 PM, the NHA confirmed that she nor any other administrative staff were made aware of Resident 1's initial report of an allegation of sexual assault on January 9, 2025. She also confirmed that she nor any other administrative staff were made aware of Resident 1's continued allegation of sexual assault on January 14, 2025. The NHA confirmed that she would expect all staff to report all allegations of abuse immediately to her. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.20(a)(5) Staff development 28 Pa. Code 201.29(a) Resident rights

Based on facility policy review, clinical record reviews, review of facility reported incidents, review of facility documentation, and staff interviews, it was determined that the facility failed to complete thorough investigations of abuse allegations and, therefore, failed to protect the safety of a resident during abuse investigations for one of four residents reviewed (Resident 1). Findings include: Review of facility policy, titled Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property, dated February 9, 2023, revealed, in part, All reports of alleged abuse/neglect shall be immediately and thoroughly investigated. The immediate response shall consist of: Social Services/Designee to interview the resident and if possible, obtain a signed statement from the resident. Interview with the person(s) reporting the alleged abuse/neglect and obtain a signed statement, if possible. Interview and obtain signed statements, if possible, from any witness or individual who has knowledge of the alleged incident. Upon notification that an employee is alleged to have committed abuse, the facility will: Ensure that the resident is safe. The individual may be suspended pending investigation. If the individual is not employed by the facility, the individual will be denied unsupervised access to the resident and visits may only be made in designated areas approved by the Executive Director/Designee. Review of Resident 1's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), chronic combined systolic diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1 clinical record revealed a progress note written by Employee 4 (Director of Social Services) dated January 8, 2025, at 2:38 PM, that indicated Resident 1's behavior care plan was updated related to delusions that may include staff that are people of color. Further review of Resident 1's clinical record progress notes revealed a progress note written by Employee 3 (a Registered Nurse) dated January 8, 2025, at 2:39 PM, that indicated Resident 1 had told the Social Worker I was out in the snow looked for the person who hit me in the head and pulled me. It was two black girls I'd know one if I saw her. The note also indicated that Resident 1 said to Employee 3 I was hit on the head and dragged into the Cat Scan. They scanned my (pointed to private area). I was so full of urine. I had to relieve myself. I peed in the trash can. Now I am being punished. Review of facility provided investigation documentation revealed a statement written by Employee 4 (Director of Social Services) dated January 8, 2025, at 10:45 AM, indicated that she had stopped by to see Resident 1 and that she was tearful and said They've maligned me in every way because I peed in the trash can. What would you do? I was out in the snow looking for the person who hit me in the head and pulled me. No other investigation or witness statements were provided as part of the investigation. Review of a facility reported incident with an original submission date of January 8, 2025, at 2:26 PM, indicated that Resident 1 had stated to Employee 4 that staff have maligned me in every way because I peed in the trashcan. What would you do? I was out in the snow looking for the person who hit me in the head and pulled me. The report further indicated that the facility was unable to identify any individual involved. Further review of this report revealed that an update was submitted on January 13, 2025, indicating that the allegation was found to be unsubstantiated as the facility was unable to identify a perpetrator. An update was submitted on January 16, 2025, that indicated, At time of accusation, resident was experiencing increased confusion and delusions. The facility reported incident failed to indicate that Resident 1 had shared a description of the alleged perpetrator(s) and said that she would be able to identify her if she saw her or that the facility had taken any measures to identify the alleged perpetrator. During a staff interview with Employee 1 (Assistant Director of Nursing) on January 30, 2025, at 10:55 AM, Employee 1 confirmed that the facility does have female staff fitting the resident's description and that one had cared for Resident 1 on one shift. Employee 1 confirmed that she had not obtained investigation or witness statements from any nursing staff regarding Resident 1's allegation and that Resident 1 had not been asked to identify the alleged perpetrator. Although, Resident 1 had provided a description and said that she would be able to identify her if she saw her. Employee 1 indicated that she usually reviews clinical notes daily. Employee 1 indicated that Resident 1 had been discussed in the daily clinical meetings because of her changes in health status. She indicated that they utilize the 24-hour report from the facility's electronic health record to discuss residents. She further indicated that this was an electronic report and that do not print them. Review of a facility reported incident with an original submission date of January 22, 2025, at 12:22 PM, indicated that on January 22, 2025, at 10:30 AM, it was discovered that Employee 2 had documented that Resident 1 had been assaulted in her genitalia in a January 9, 2025, and January 14, 2025, progress note. Further review of this report revealed that an update was submitted on January 27, 2025, indicating that Employee 2 did not communicate the Resident's concern to any facility staff member; and on January 28, 2025, indicating that Employee 1 had provided Employee 2 with education on the abuse policy, and he was given a copy of the policy. Review of provided investigation documentation revealed a statement written by Employee 5 (a Social Worker) which indicated that they had interviewed Resident 1 on January 22, 2025, and Resident 1 stated that she was hit on the head and a nurse was sticking something sharp inside of me. The resident also described the appearance of the two alleged employees. During a staff interview with the Nursing Home Administrator (NHA) on January 30, 2025, at 12:07 PM, the NHA indicated that, during daily clinical meeting, the interdisciplinary team reviews incidents and accidents, as well as verbal nursing reports. She said that the facility's electronic health record pulls a 24-hour report that reveals notes that have occurred in the prior 24 hours so that appropriate follow-up can be completed or initiated. When asked if open investigations are reviewed during this meeting, the NHA indicated that it depends on where they are in the investigation process and sometimes; they are not done in this meeting because of the nature of the investigation. The NHA attempted to pull 24-hour history reports from prior dates, but the system would not enable the report to be pulled. At time of conclusion of field office investigation on January 30, 2025, at 3:25 PM, the facility was unable to provide any documentation that indicated they had obtained investigation or witness statements from any nursing staff regarding Resident 1's abuse allegations or that Resident 1 had been asked to identify the alleged perpetrator(s). Although, Resident 1 had again provided a description and that she would be able to identify her if she saw her. During a staff interview with the NHA and Employee 1 on January 30, 2025, at 3:32 PM, the NHA confirmed that the facility had not thoroughly investigated Resident 1's allegations of abuse. She confirmed that Resident 1 was never asked to identify the alleged perpetrator(s); although, Resident 1 had provided a physical description and said that she would be able to identify her if she saw her again on two separate occasions over a 14-day timespan. The NHA confirmed that no staff members were suspended while the facility was completing the investigations for Resident 1. The NHA indicated that she would expect all abuse investigations to be completed thoroughly to enforce resident safety. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for two of three residents reviewed (Residents 65 and 72). Findings include: Review of facility policy, titled Procedure: Guidelines For Prevention of Catheter Associated Urinary Tract Infections, with a last review date of January 25, 2024, revealed that Special meatus [opening leading to the interior of the body] care with an indwelling urinary catheter is not required. Daily soap and water cleansing of the perineal area is an important part of the hygiene for all patients. Review of Resident 65's clinical record revealed diagnoses that included urinary retention (a condition where your bladder doesn't empty all the way or at all when you urinate) and use of an indwelling foley catheter (a tube placed and held in the bladder to drain urine). Review of Resident 65's nurse aide task documentation from October 1, 2024, through December 12, 2024, revealed that there was no documentation of catheter care being provided as follows: October: 6th evening shift; 11th evening shift; 18th evening shift; 19th night shift; 21st day and evening shift; 22nd day and evening shift; 23rd evening shift; 27th day shift; 30th evening shift; November: 4th day shift; 8th day and evening shift; 13th evening shift; 14th day shift; 18th day and evening shift; 22 day and night shift; 24th day shift; 29th night shift; and December: 1st evening shift; 2nd day shift; 3rd evening shift; 5th evening and night shift; 6th evening shift; 7th evening and night shift; and 8th evening shift. Further review of Resident 65's clinical record revealed that the Resident was diagnosed with a urinary tract infection (UTI) on October 25, 2024, and that their final urine culture dated October 28, 2024, indicated that their urine contained greater than 100,000 CFU/ml of E-coli (Escherichia coli-a bacteria that lives harmlessly in your gut which can cause an infection if it enters your urinary system from stool). During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2024, at 1:44 PM, they both confirmed that they would expect catheter care to be provided and documented every shift. Review of Resident 72's clinical record revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland) and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 72's physician orders revealed orders for catheter check every shift, with a start date of September 27, 2024. Review of Resident 72's nurse aide task documentation from October 1, 2024, through December 10, 2024, revealed that there was no documentation of catheter care being provided as follows: October: 10th night shift; 12th night shift; 16th evening shift; 30th evening shift; 31st evening and night shift; November: 1st night shift; 2nd evening shift; 6th day shift; 12th evening shift; 13th day shift; 25th day shift; December: 3rd evening shift; and 10th evening shift. Further review of Resident 72's clinical record revealed he was started on an antibiotic for a UTI on October 27, 2024, twice daily for seven days; and on December 9, 2024, daily with a stop date of December 20, 2024. Interview with the DON on December 11, 2024, at 1:58 PM, revealed she would expect catheter care to be completed and documented per facility protocol, daily every shift. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed (Resident 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and muscle weakness. Review of Resident 27's care plan revealed that the Resident had an impaired functional status and approaches/interventions included transfers: 1-person assist, stand pivot with a walker and to have right AFO (Ankle Foot Orthotic - braces support the ankle, keeping the toes aligned with the rest of the foot) on for transfers and when OOB [out of bed], OOB to pedal Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with cushion and bilateral leg rests for proper positioning, dated January 27, 2024; and Walking: non-ambulatory, dated January 27, 2024. Observation of Resident 27 on December 9, 2024, at 10:26 AM, revealed that the Resident was in their room, seated in their Broda chair with no leg rests, leaning slightly to the left, and that the Resident had slippers on both feet. The leg rests for the Broda chair, their AFO, and their shoes were noted on the floor nearby in front of a nightstand. Observation of Resident 27 on December 10, 2024, at 10:18 AM, revealed that the Resident was in their room, seated in their Broda chair with leg rests present, and that the Resident had gripper socks on both feet. Their AFO and shoes were noted on the floor nearby in front of a nightstand. Observation of Resident 27 on December 10, 2024, at 12:52 PM, revealed that the Resident was in the dining room, seated in their Broda chair with leg rests in place, and the Resident had on sneakers. The AFO was not present. Immediate observation of Resident 27's room revealed that their AFO was present in their room on the floor in front of the nightstand. Observation of Resident 27 on December 11, 2024, at 10:09 AM, revealed that the Resident was in their room, seated in their Broda chair with leg rests present, and that the Resident had their AFO in place and was wearing sneakers. Review of Resident 27's Physical Therapy Discharge Summary dated November 22, 2024, revealed that Discharge Recommendations included a Restorative Nursing Program (RNP) for sit to stand transfers and bilateral lower extremities therapeutic exercises in order to maintain current level of function. In addition, it was noted that Resident 27's long-term therapy goal for Pt. will ambulate 25 feet safely with front wheeled walker and min assist (25% assist) on even surfaces was discontinued on November 22, 2024, and stated rationale indicated ambulation discontinued due to decreased safety. This discharge summary failed to include any mention of Resident 27's AFO. Review of Resident 27's nurse aide task documentation revealed that the Resident was on a Restorative Nursing Program for range of motion and walking. Review failed to reveal any documentation regarding Resident 27's use of their AFO. Further review of this documentation from November 22, 2024, through December 11, 2024, revealed that on November 25 and 27, 2024; December 4 and 9, 2024, there was no documentation indicating that Resident 27 was provided their range of motion or ambulation programs. In addition, it was noted that on November 30, 2024, and December 1, 2, 3, and 6, 2024, there was no documentation that Resident 27 was provided their ambulation program. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2024, at 1:50 PM, concerns were shared regarding the observations of Resident 27, missing RNP documentation, missing AFO documentation, and conflicting information regarding Resident 27 being non-ambulatory, but on a walking RNP. During a staff interview with the NHA on December 12, 2024, at 9:49 AM, the NHA indicated that Resident 27's walking program was placed on hold sometime back in July. The NHA said she was not sure why it would have been still populating for staff to perform/document. She confirmed that the Resident 27's care plan indicated that she was non-ambulatory and that the therapy discharge summary indicated on November 22, 2024, that ambulation was not safe. During a final staff interview with the NHA and DON on December 12, 2024, at 11:12 AM, the NHA indicated that she had no additional information to provide regarding Resident 27's AFO use or why staff would be ambulating Resident 27 if they were not ambulatory. The NHA confirmed that she would expect range of motion exercises to have been provided and documented accordingly, and that she would expect Resident 27's care plan to have been followed for the use of their AFO. 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status and failed to notify the physician of a significant weight change for two of 21 residents reviewed (Residents 38 and 79). Findings include: Review of facility policy, titled Procedure: Weighing and Documenting Resident Weights, last reviewed January 25, 2024, read, in part, Unit coordinators review weights and transfer all weights to include any re-weights to resident medical records via Care Tracker. Dietitian will notify nursing via Kardex of any significant weight loss or weight gain, as well as physician after reviewing the weight detail report in Care Tracker. If nurse aide reports a variance, weight must be done again in presence of a licensed staff on that shift. A weight variance is defined as any resident weighing greater than 120 pounds with a gain or loss of five pounds or more, or a resident weighing less than 120 pounds with a weight gain or loss of three pounds or more. Admission weekly weights will be obtained for four weeks post admission from day of admission. Review of Resident 38's clinical record revealed diagnoses that included moderate protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 38's physician orders revealed an order for Weekly weight Tuesday day shift- every week, with a start date of November 26, 2024. Review of Resident 38's clinical record revealed he had a significant weight loss of 20.8 pounds (11.9%) from November 3 to 26, 2024. Further review of Resident 38's clinical record revealed he was not weighed again until December 3, 2024. Review of Resident 38's clinical record revealed a dietitian note on November 26, 2024, in response to the weight loss that read, in part, Unsure if weight loss is true weight loss or water loss. Recommend fortified cereal to increase caloric intake. Further review of the dietitian note on November 26, 2024, failed to reveal documentation that the physician was notified. During an email correspondence with the Nursing Home Administrator (NHA) on December 10, 2024, at 12:27 PM, the surveyor inquired if there had been communication to the physician related to Resident 38's significant weight change. Interview with Employee 1 (Physician Assistant) on December 11, 2024, at 10:56 AM, revealed he was notified of Resident 38's weight loss the previous evening of December 10, 2024, by nursing. He further revealed he is typically only notified of significant weight changes that the nursing staff are concerned about, and he rarely has communication with the dietitian. Interview with the NHA on December 11, 2024, at 1:55 PM, the surveyor revealed the concern with the missed re-weigh measure for the weight variance and lack of physician notification of resident 38's significant weight loss. The NHA revealed she would expect weight monitoring and physician notification per facility policy. Review of Resident 79's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and osteoporosis (a condition that weakens bones and increases the risk of fractures). Review of Resident 79's physician orders revealed an order for Weekly weight Tuesday 3-11 shift weights- every week, with a start date of September 17, 2024. Review of Resident 79's clinical record failed to reveal a weekly weight measure was obtained during the week of September 15 through 21, 2024. Interview with the NHA and Director of Nursing on December 12, 2024, at 11:16 AM, revealed they are unable to locate a weekly weight measure between the aforementioned dates, and she would expect weekly weights to be obtained per physician order and facility policy. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and two of two dining areas. Findings include: Review of facility policy, titled Food Storage, revealed, Food storage areas shall be maintained in a clean, safe, and sanitary manner. The surveyor requested a food storage labeling policy that pertains to labeling and dating of food items on [DATE], at 2:20 PM. No further policies were provided. Observation of the walk-in freezer unit on [DATE], at 11:51 AM, revealed three packs of onion rings not dated. Interview with Employee 1 (Food Service Director) on [DATE], at 11:52 AM, revealed food items should be labeled with the date they are received if they are removed from the original package. Observation of the walk-in refrigerator on [DATE], at 11:53 AM, revealed a container of shredded mozzarella cheese labeled ,d+[DATE] and some of the cheese had turned blue; one bin of celery dated ,d+[DATE] that was brown and wilted; one bin of cabbage labeled ,d+[DATE] and the outer leaves of the cabbage were black; and one box of tomatoes without a date, and half of the tomatoes were rotten. Interview with Employee 1 on [DATE], at 11:55 AM, revealed produce is labeled with the date it was received, and should be used before it goes bad or tossed when it goes bad. Observation in the main kitchen on [DATE], at 11:56 AM, revealed two containers of crisped rice cereal, one was dated ,d+[DATE] and one was dated ,d+[DATE]. Interview with Employee 1 on [DATE], at 11:57 AM, revealed the bins have been filled since those dates and should be relabeled. Observation during initial tour of the [NAME] dining area refrigerator on [DATE], at 12:05 PM, revealed one container of apple juice labeled ,d+[DATE] that was open; one container of apple juice labeled ,d+[DATE] that was open; one container of cranberry juice labeled ,d+[DATE] that was open; and two containers of thickened orange juice labeled ,d+[DATE] that were open. Observation of the [NAME] dining area freezer on [DATE], at 12:07 PM, revealed one box of ice cream sandwiches without a date, and they appeared freezer burned; two lime sherbet without a date; and one orange sherbet without a date. Observation during initial tour of the Courtyard dining area on [DATE], at 12:17 PM, revealed 29 boxes of cereal varieties all not labeled with use by dates. Observation of the Courtyard dining area refrigerator on [DATE], at 12:17 PM, revealed two containers of tomato juice labeled ,d+[DATE] and they were open; one container of grape juice labeled ,d+[DATE] and it was open; one container of cranberry juice labeled ,d+[DATE] and it was open; one container of ketchup without a date; and one container of mustard without a date. Observation of the pantry in the Courtyard dining area on [DATE], at 12:19 PM, revealed one bag of wheat bread with a best by date of [DATE]; one bag of white bread with a best by date of [DATE]; and one bag of bagels not dated. Observation of the Courtyard dining area refrigerator on [DATE], at 12:21 PM, revealed one bin of ice cream sandwiches without a date; and 10 lime sherbet without a date. Interview with Employee 1 on [DATE], at 12:24 PM, revealed the facility's process is to label juices with their received date once removed from the original package; juices should be labeled with an open date once open and discarded after seven days; freezer items not dated should be labeled with a use by date; cereals, condiments, and breads should be dated; and food items should be discarded once past their best by date. Interview with the Nursing Home Administrator on [DATE], at 12:20 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility process, and that food and beverage items are stored and utilized in accordance with professional standards, and discarded once expired. 28 Pa. Code 211.6(f) Dietary services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 22 residents reviewed (Resident 75). Findings Include: Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 75's physician orders revealed orders for checking and irrigation of a foley catheter, starting December 14, 2023. Review of Resident 75's care plan revealed a focus area [Resident 75] does have continence issues with a subsection, [Resident 75] uses: Bathroom, pull-ups, foley, with a start date of December 14, 2023. Review of Resident 75's Comprehensive MDS assessment (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an ARD (assessment reference date - last day of the assessment period) of December 21, 2023, revealed, Section H: Bowel and Bladder, subsection H0100. Appliances, Resident 75 was coded Z. None of the above under subsection H0100, which included an indwelling catheter. During an interview with the Nursing Home Administrator (NHA) on January 17, 2024, at 12:25 PM, the surveyor inquired about the accuracy of Resident 75's comprehensive assessment regarding the catheter. Email correspondence with the NHA on January 17, 2024, at 7:29 PM, revealed the MDS assessment had been modified to reflect that Resident 75 had a catheter. Follow-up interview with the NHA on January 18, 2024, at 11:40 AM, revealed it was the facility's expectation that the Resident MDS would be coded accurately. 28 Pa. Code 211.5(f) Clinical records

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to reflect the resident's current status for two of 22 residents reviewed (Residents 57 and 75). Findings include: Review of Resident 57's clinical record revealed diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and chronic kidney disease (CKD - gradual loss of kidney function). Review of Resident 57's current care plan on January 17, 2024, at 11:02 AM, revealed the following information: Resident 57 wore bilateral hearing aides, and staff were to ensure that the appliances were clean and in working order; Resident 57 was actively being treated for a UTI (Urinary Tract Infection); and Resident 57 was at risk of dehydration due to a 1600 cc per day fluid restriction. Observation of Resident 57 on January 17, 2024, at 1:00 PM, revealed he was not wearing any hearing aides. During an immediate interview with Employee 2, she confirmed that Resident 57 was not wearing hearing aides and that his wife had taken them home. Review of Resident 57's physician orders revealed no current orders for treatment of a UTI. Review of nursing progress notes revealed that the last notation made regarding treatment/tracking of a UTI was November 21, 2023, when it was noted that there were not signs or symptoms of a UTI or adverse reactions to previous antibiotic treatment. Review of Resident 57's current physician orders revealed an order for 1800 cc per day fluid restriction, effective December 19, 2023. During an interview with the Nursing Home Administrator (NHA) on January 18, 2024, at 11:50 AM, she revealed that Resident 57's care plan was updated to reflect that his hearing aides were not in use, and that Resident 57's care plan was under revision to ensure it reflected the correct fluid restriction amount. During a later interview with the NHA on January 18, 2024, at 2:40 PM, she acknowledged that Resident 57's care plan still included information about active treatment of a UTI, confirmed that Resident 57 was not currently receiving treatment for a UTI, and revealed that the care plan would be updated. Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Review of Resident 75's current care plan on January 16, 2024, at 2:00 PM, revealed the following information: Resident 75 was actively being treated for a UTI; and that he had an unstageable pressure ulcer. Review of Resident 75's Comprehensive MDS assessment (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an ARD (assessment reference date - last day of the assessment period) of December 21, 2023, revealed Resident 75 was coded as having a stage III pressure ulcer. Email correspondence with the NHA on January 17, 2024, at 11:56 AM, the surveyor inquired about when Resident 75's pressure ulcer changed stages, and if he currently had an UTI. Review of select facility documentation provided on January 17, 2024, at 1:05 PM, revealed Resident 75's pressure ulcer changed from unstageable to stage III on December 21, 2023, and that Resident 75's UTI had resolved on January 8, 2023. Follow-up interview with the NHA on January 18, 2024, at 11:40 AM, revealed she would expect Resident 75's care plan to be updated to reflect the current stage of his wound and that he no longer has an UTI. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on review of the clinical records and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the residents needs; and failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 22 residents reviewed (Resident 70 and 75). Findings include: Review of Resident 70's clinical record revealed diagnoses that included noninfective gastroenteritis and colitis, unspecified (inflammation of the stomach and intestines), and hypomagnesemia (electrolyte imbalance caused by a low level of magnesium in the blood). During an interview with Resident 70 on January 17, 2024, at 10:10 AM, she stated she has been suffering from diarrhea for several weeks. She reported the diarrhea to be severe causing her to be incontinent at times, and she stated, they can't seem to figure out what is causing it. Further review of Resident 70's clinical record on January 18, 2024, at approximately 10:30 AM, revealed a hospital discharge summary indicating she was admitted [DATE], to December 26, 2023, for electrolyte derangement (an imbalance of electrolytes in the blood) and diarrhea. Review of the hospital discharge summary revealed multiple stool tests were collected on December 18, 2023, and the results were pending at the time of discharge. The discharge summary also instructed to follow-up with outpatient gastroenterology (physicians that focus on the digestive system and disorders). Further review of Resident 70's clinical record failed to reveal results from any stool testing and a follow-up appointment for outpatient gastroenterology. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 18, 2024, at 11:50 AM, results of the stool testing and information on a follow-up gastroenterology appointment were requested. In a follow-up interview with the NHA and DON on January 18, 2024, at 2:47 PM, the NHA stated a call had been placed to the hospital requesting results of the stool testing. She also stated a call had been placed to the facility physician and Resident 70's family to check if further gastroenterology follow-up and treatment is wanted. During an additional interview with the DON on January 18, 2024, at 3:54 PM, results from the stool testing were provided. Review of the results provided revealed Resident 70's calprotectin stool test (a test used to check for inflammation in the intestines) results were 525 mcg/g (micrograms/gram). The reference range indicated a normal calprotectin level is less than 50 mcg/g and levels greater than 120 mcg/g are elevated. The DON stated that after the facility physician reviewed the results of the testing, he had ordered a follow-up with gastroenterology and the facility has placed a call to schedule an appointment. The DON confirmed the result of testing should have been obtained and reviewed, and the follow-up appointment should have been scheduled when Resident 70 returned from the hospital. Review of Resident 75's clinical record revealed diagnoses that included pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin), basal cell carcinoma of skin (skin cancer), and obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating). Review of Resident 75's care plan revealed a focus area for skin conditions [Resident 75] is at risk for skin impairment/pressure ulcers related to impaired mobility and incontinence; unstageable pressure on coccyx, with an intervention for treatment as ordered, with a start date of December 14, 2023. Further review of Resident 75's care plan focus area for skin conditions revealed, [Resident 75] has a lower back wound that may be a malignancy, with an intervention for, Be seen by MD and receive debridement until healed, with a start date of December 28, 2023. Review of Resident 75's physician orders revealed an order for Sacral wound care- Once daily night shift. Cleanse with NSS and pat dry. Fluff and apply Calcium Alginate with Ag and cover with bordered gauze daily at night. May replace if soiled or lifted. Code: 1 = no sign of infection, 2 = sign of infection, note required, 3 = small amount of drainage, 4 = moderate amount of drainage, 6 = no pain, 7 = signs/symptoms of pain. For sacral wound once daily. Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate the treatment order was completed on January 9, 2024. Review of Resident 75's physician orders revealed an order for Dressing change LL (left lower) back .once daily wash area of LL back and pat dry. Fluff and apply Ca Alg (Calcium Alginate- wound treatment) to wound bed and cover with bordered gauze. May replace if soiled or lifting. For back wound once daily, with a start date of December 21, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate the treatment order was completed on January 2 and 9, 2024. Interview with the NHA on January 18, 2024, at 11:40 AM, revealed she did not have any information to provide related to the missing documentation, and she would expect physician orders to be followed and documented as completed. 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 ensure physician orders were followed for catheter care for one of two residents reviewed for catheters (Resident 75). Findings include: Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 75's physician orders revealed an order for Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift, with a start date of December 14, 2023, and an end date of December 28, 2023. Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, day shift; and December 23 and 26, 2023, night shift. Review of Resident 75's physician orders revealed an order for Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, once daily, with a start date of December 14, 2023, and an end date of December 18, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed for the duration of the order. Review of Resident 75's physician orders revealed an order for Catheter Graduated Container Change Type - Catheter Care - Once daily (weekly on Saturday). Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 16, 2023. Review of Resident 75's physician orders revealed an order for Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift, with a start date of December 28, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 12, 2024, day shift; January 8, 12, and 14, 2024, evening shift; and December 30, 2023, and January 9, 2024, night shift. Review of Resident 75's physician orders revealed an order for Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, every shift, with a start date of December 18, 2023. Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, and January 12, 2024, day shift; December 18, 2023, and January 8, 12, 14, 2024, evening shift; and December 18, 23, 26, and 30, 2023, and January 9, 2024, night shift. Interview with the Nursing Home Administrator on January 18, 2024, at 11:40 AM, revealed she would expect physician orders to be followed and documented as completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 21 residents reviewed (Residents 21, 40, 51). Findings include: Review of Resident 21's clinical record revealed diagnoses that included diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream) and Parkinson's disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts). Review of Resident 21's October 12, 2022 comprehensive and December 13, 2022 quarterly MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident, such as a resident's physical, mental, or psychosocial needs) revealed that these assessments were coded to indicate that Resident 21 received insulin one time during each look back period (seven days prior to the aforementioned dates). Review of Resident 21's October 2022 and December 2022 MARs (Medication Administration Records - form used to document physician orders as well as when and how medications are administered to a resident) failed to reveal that the Resident received insulin during that time. During an interview with the Nursing Home Administrator (NHA) on February 23, 2023, at 10:47 AM, she confirmed that the aforementioned MDS assessments were coded in error and were being corrected. Review of Resident 40's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and hypertension (high blood pressure). Review of Resident 40's clinical record revealed that they had a Stage 2 pressure ulcer that resolved on January 29, 2023. Review of Resident 40's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of October 5, 2022, revealed in section M Skin Conditions that Resident 40 had no pressure ulcers noted. Review of Resident 40's Annual Comprehensive MDS with the assessment reference date (last day of the assessment period) of January 3, 2023, revealed in section M Skin Conditions, that Resident 40 had a Stage 2 pressure ulcer and that the pressure ulcer was present upon admission. Further review of Resident 40's clinical record revealed that they had been in the facility between October 5, 2022, and January 3, 2023, with no transfers out of the facility. During an interview with Employee 4 on February 22, 2023, at 2:33 PM, Employee 4 revealed that the pressure ulcer was coded incorrectly as being present upon admission. Email communication received from the NHA on February 22, 2023, at 6:48 PM, revealed that a correction had been made to the MDS. Review of Resident 40's current physician orders revealed an order for risperidone (an antipsychotic medication used to treat certain psychiatric conditions) 0.5 mg, take one tablet in the evening. Further review of Resident 40's clinical record revealed that they have been followed by Psycho-Geriatric Services (PGS) and their primary care physician for management of the antipsychotic medication. PGS visit note dated May 3, 2022, indicated after careful consideration, the benefits of antipsychotic medications in this patient outweigh the potential risks of tardive dyskinesia (disorder that results in involuntary repetitive body movements), hyperglycemia (elevated blood sugar), and stroke. GDR (gradual dose reduction) contraindicated due to uncontrolled and unsafe behaviors. Review of Resident 40's Quarterly MDS's with the assessment reference date of July 6, 2022, and October 5, 2022, and their Annual Comprehensive MDS with assessment reference date of January 3, 2023, revealed in section N Medications, that there had been no documented contraindication to a gradual dose reduction. During an interview with Employee 4 on February 22, 2023, at 2:33 PM, Employee 4 revealed that the gradual dose reduction contraindication date should have been on the MDS's with assessment reference dates of July 6, 2022; October 5, 2022; and January 3, 2023. Email communication received from the NHA on February 22, 2023, at 6:48 PM, revealed that corrections had been made to the MDS's. During an interview with the NHA and Director of Nursing on February 23, 2023, at 1:11 PM, they both confirmed that they would have expected the MDS's to be completed accurately. Review of Resident 51's clinical record revealed diagnoses that included Cerebral Palsy and unspecified intellectual disabilities. Review of Resident 51's quarterly MDS assessment, dated December 6, 2022, revealed that in Section O, Restorative Nursing Programs- Record, the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last seven calendar days (enter 0 if none or less than 15 minutes daily), splint or brace assistance was coded as 0. Review of Resident 51's daily charting for splint or brace assistance device 1 minutes, dated November 30, 2022, through December 6, 2022, revealed that three of the seven days were documented as 15 minutes. During an interview with the NHA on February 23, 2023, at 1:17 PM, she confirmed that Resident 51's MDS was coded incorrectly. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the residents' comprehensive plans of care were updated upon changes in the resident's condition for five of 21 residents reviewed (Residents 19, 21, 40, 43, and 60). Findings include: Review of facility policy, titled Care Plans-Comprehensive dated 2013, revealed 4. Care Plan Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. Review of Resident 19's clinical record revealed diagnoses that included peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Review of Resident 19's current physician orders revealed order for a pureed diet effective January 2, 2023. Review of Resident 19's care guide on February 22, 2023, at 1:00 PM, revealed that the care guide indicated Resident 19 was on a regular diet with chopped meat as well as a pureed diet. During an interview with the Nursing Home Administrator (NHA) on February 23, 2023, at 10:48 AM, she confirmed that the care guide was not accurate and that it was being revised for accuracy. Review of Resident 21's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Review of Resident 21's current physician orders revealed an order to obtain weekly weights, effective January 6, 2023. Review of Resident 21's care plan on February 22, 2023, at 10:15 AM, revealed that it indicated that Resident 21 was to be weighed monthly. During an interview with the NHA on February 23, 2023, at 2:07 PM, she confirmed that the care plan needed to be corrected, and that they were in the process of reviewing to ensure that the care plans reflected current orders. Review of Resident 40's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and hypertension (high blood pressure). Review of Resident 40's clinical record revealed that they had a Stage 2 pressure ulcer that resolved on January 29, 2023. Review of Resident 40's care plan revealed a care plan focus for: has a sacral pressure ulcer. Notations under the care plan focus indicated October 26, 2022, Stage 2 coccyx area January 29, 2023 Stage 2 resolved. Although documentation indicated that Resident 40's pressure ulcer resolved and was now a potential problem, the care plan focus was not changed to identify the change in Resident 40. During an interview with the NHA and Director of Nursing (DON) on February 23, 2023, at approximately 10:45 AM, both confirmed that they would have expected the care plan to be updated to reflect the change from an actual alteration to a potential for alteration. Review of Resident 43's clinical record revealed diagnoses that included diastolic congestive heart failure (chronic condition in which the heart cannot fill adequately) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Review or Resident 43's current physician orders revealed an order for 1500 cc fluid restriction daily, dated February 15, 2023. Review of Resident 43's care plan revealed a care plan focus for Resident on a therapeutic diet and fluid restriction with an approach (intervention) of 1800 cc fluid restriction encourage compliance. NHA provided a revised care plan for Resident 43 to reflect the 1500 cc fluid restriction by email on February 23, 2023, at 9:23 AM. During an interview with the NHA and DON on February 23, 2023, at approximately 10:37 AM, both confirmed that they would have expected the care plan to be updated when the order was changed. Review of Resident 60's care plan on February 22, 2023, revealed diagnoses of Cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and Dysphagia (the medical term for swallowing difficulties). Further review revealed a care plan with a goal of: tube feeding due to Cerebral infarction and Dysphagia; had an action listed as: Glucerna 1.2 at 60 cc/hour with 10 ml flush every hour x 20 hours. Off from 10:00 AM to 2:00 PM daily. Review of Resident 60's current physician's orders on February 21, 2023, revealed a physician's order for Glucerna 1.2 at 60 cc per hour, continuously for 10 hours from 8:00 PM to 6:00 AM daily. Interview with the NHA on February 23, 2023, at 11:00 AM, revealed that she is aware that there are inconsistencies on some of the care plans and that they are already planning on correcting the problem. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for two of three residents reviewed for limited range of motion (Residents 23 and 51). Findings Include: Review of Resident 23's clinical record revealed diagnoses that included hemiplegia and hemiparesis of left side (inability to move, severe weakness, or rigid movement on either the right or left side of the body) following cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) and contracture of left hand (tightening of tissue of the palm of the hand leading to the bending of the fingers). During an interview with Resident 23 on February 21, 2023, at 10:10 AM, she expressed concern that therapy services had ended and that restorative nursing (program available in nursing homes that helps residents maintain any progress they've made during therapy treatments) exercises were not always being done with her. Review of Resident 23's current care guide revealed that she was to receive passive range of motion to her left upper extremity/hand, flexion and extension all planes for 8-10 minutes on 3 PM -11 PM shift daily. Review of Resident 23's restorative nursing documentation for the period of January 21, 2023, through February 21, 2023, revealed 21 instances where it was not documented that she received at least 8 minutes of restorative services daily. During an interview with Employee 7 (Registered Nurse Assessment Coordinator) on February 23, 2023, at 1:14 PM, she revealed that she had no explanation as to why Resident 23 did not receive at least 8 minutes of restorative services each day. When informed of the concern on February 23, 2023, at 1:18 PM, the Nursing Home Administrator (NHA) had no additional information to provide. Review of Resident 51's clinical record revealed diagnoses that included Cerebral Palsy and unspecified intellectual disabilities. Observation of Resident 51 on February 21, 2023, at 9:58 AM, revealed that Resident 51's right hand was contracted and there was no splint/brace present. Resident 51's left hand was under her blanket and was unable to be visualized at this time. An additional observation of Resident 51 on February 21, 2023, at 11:17 AM, revealed that Resident 51's right and left hand were contracted and there was no splint/brace present on either hand. During an interview with Resident 51's Responsible Party at this time, who visits almost daily, Resident 51's Responsible Party was asked if Resident 51 ever wears splints or braces to her hands. Resident 51's Responsible Party answered no but stated she was told therapy was going to be started the next day for Resident 51's hands. During an interview with Employee 3 (Rehab Program Director) on February 23, 2023, at 10:30 AM, she stated that Resident 51 was discharged from OT in October 2022, with recommendations for palm guards. Employee 3 stated that nurse aides were educated on Resident 51's palm guards and, since therapy staff is unable to educate every nurse aide, the nurse aides who were given education would educate other nurse aides. Employee 3 stated that when palm guards or any restorative nursing program is recommended, the RNAC (Registered Nurse Assessment Coordinator) is responsible for following through with the program. Employee 3 also stated that Resident 51 is being re-evaluated this week to see if any changes need to be made with her current palm guards, as Employee 3 feels they may not be fitting Resident 51 properly. Review of Resident 51's Occupational Therapy (OT) discharge summary, dated October 27, 2022, revealed that Resident 51 will tolerate bilateral upper extremity palmar guards for four to six hours in order to promote skin integrity. Patient demonstrates improved tolerance of bilateral palm guards, with decreased risk of skin tear. Staff is educated on wear schedule. Further review of the discharge summary revealed that the discharge plan and instructions include bilateral palm guards. Review of Resident 51's facility form, titled Resident Care Guide, which is part of Resident 51's current care plan, revealed a restorative nursing program was to be started on October 29, 2022, with instructions to Apply stockinette to bilateral hands to protect skin from breakdown, Step 2 apply bilateral hand palm guard splint after AM care for 4 hours on 7-3. Remove stockinette & splint at last round of 7-3 shift. Observation of Resident 51 on February 22, 2023, at 10:45 AM, revealed Resident 51 was not wearing her bilateral palm guards. During an interview with Employee 4 (RNAC), on February 23, 2023, at 11:19 AM, she stated that, according to nursing, Resident 51 does not always wear the palm guards, but stated that there is no documentation of refusals. Review of nurse aide education, dated October 27 2022, and October 28, 2022, revealed that four nurse aides signed off on receiving education for Resident 51's palm guards. The education included applying a stockinette under the palm guards, wearing a max of four to six hours a day, and to check skin integrity when removing the palm guards. Review of Resident 51's daily charting for splint or brace assistance device 1 minutes, dated November 30, 2022, through December 6, 2022, revealed three days were documented as 15, three days were documented as 0 and on one day, December 6, 2022, there was no documentation for splint or brace assistance. Review of Resident 51's daily charting for splint or brace assistance device 1 minutes, dated January 23, 2023, through February 22, 2023, revealed that 26 of those days it was documented as 0, four of those days it was documented as 15 and on one day, February 21, 2023, there was no documentation for splint or brace assistance. During an interview with the Director of Nursing (DON) on February 23, 2023, at 2:05 PM, she stated that 0 means it did not occur and 15 means it occurred for 15 minutes. At this time, the NHA and DON were made aware of the aforementioned documentation of 0, 15, and the missing documentation for two days. They were also made aware of the observations of Resident 51 not wearing her palm guards. No additional information was provided. 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to accurately assess, monitor, and report weight changes to the physician and implement timely interventions to prevent weight loss for one of 13 residents reviewed (Resident 1). Findings include: Review of the clinical record revealed that Resident 1 was originally admitted to the facility in 2007. Current [DIAGNOSES REDACTED]. Review of the Weights Detail Report revealed the following weights: 153 pounds on October 3, 2012, 151 pounds on November 2, 2012, 138 pounds on December 9, 2012 ( a loss of 13 pounds and greater than 7.5 %), 135.5 pounds on January 1, 2013, 138 pounds on February 1, 2013, and 119 pounds on March 5, 2013 (a loss of 19 pounds and greater than 10%). Total weight loss was 34 pounds over 154 days. Review of the clinical record revealed that Resident 1 had a suspected aspiration on October 23, 2012 with subsequent speech therapy consultation. Speech therapy recommendations included a pureed diet, honey thick liquids, and limiting pureed foods and fluids to 1 level teaspoon at a time. Review of the Minimum Data Set (MDS- a periodic assessment of needs) dated November 5, 2012 and February 5, 2013, revealed that Resident 1 required maximum assistance with eating. Review of the Physician orders revealed a diet order of pureed food with honey thick liquids. Review of the Quarterly Nutrition Risk assessment dated [DATE] revealed a score of 3 or moderate risk. The Dietician notes indicated no swallowing issues, no snack or supplement, and monitor intakes due to change in diet consistency. Review of the Meal Intake Detail Report revealed no documented meal intakes between November 7, 2012 and December 24, 2012. Review of the clinical record revealed a note by the Dietician dated December 23, 2012 stating "weight down in last month, no meal intakes at present will request for 5 days and reweigh, no new labs". A note by the Dietician dated December 31, 2012, stated "weight decrease confirmed, question if related to diet down grade, intakes 70%, will continue to follow monthly". There were no available notes by the Dietician in January. A note by the Dietician dated February 15, 2013 acknowledged a Stage 3 wound, no new labs, 67-92% meal intake, suggest multivitamin and protein powder twice a day, will follow progress. Review of the Quarterly Nutrition Risk assessment dated [DATE], revealed the Dietician notes indicated no swallowing issues, no snack or supplement, BMI ok, 42-92% intake, and down 8.6% in one month, likely dysphagia. Review of the Meal Intake Detail Report revealed intakes were documented from December 24, 2012 to December 27, 2012. During an interview on March 12, 2013 at 10:00 a.m., the DON stated that the facility does not routinely document meal intakes for all residents. She stated that if the Dietician wants to monitor intakes she has to go into the computer and turn on the intakes to alert staff to document. She stated that staff always have the ability to document intakes if they notice a resident is eating less than 50%. The DON stated that the Kardex is used for staff communication of issues regarding the residents. Review of the Kardex revealed no documentation by the Dietician of a significant weight loss, or notification to the Physician. Review of the physician progress notes [REDACTED]. The note dated November 28, 2012, stated "continues to slowly worsen". A review of the Care Plan revealed no care plan or interventions for nutrition or weight loss. Review of the clinical record revealed no lab work for review. During an interview on March 13, 2013 at 1:45 p.m., the Dietician stated she first noticed a significant weight loss in Resident 1 at the end of December 2012. When asked why there were no meal intakes as she requested in November, she responded that she saw that the meal intakes were being documented in the computer and assumed they would continue. She acknowledged she did not communicate to the nursing staff that she wanted to monitor intakes. She stated that she requested meal intakes be documented at the end of December 2012 and because the resident was eating 70-80% she did not feel she needed to monitor anymore. When asked if Resident 1 was a candidate for a nutritional supplement, she stated that she usually talks to the nursing staff and Physician to ask if a supplement is needed. She stated that she did not remember if she talked to staff. When asked if she notified the Physician of the significant weight loss, she stated she could not remember. When asked if she followed up with Resident 1 in January, she stated that if she had she would have written a note. She acknowledged that Resident 1 should have had a care plan addressing nutrition and weight loss. During an interview on March 13, 2013 at 3:08 p.m., the Regional Dietician stated that Resident 1 had a significant weight loss and no interventions were put into place. She was not assessed for a nutritional supplement and should have been. The Regional Dietician stated standards of practice dictate acceptable interventions would have been monitoring meal intakes, weekly weights, assessing food preferences, and assessing for nutritional supplements. Review of the facility policy statement titled Nutritional Care revealed each resident will be assessed, have nutritional needs identified, and initiate interventions to achieve or maintain nutritional status, and an interdisciplinary plan of care shall be maintained incorporating nutritional needs. Review of the facility protocol titled Weighing and Documenting Resident Weights revealed the Dietician will notify nursing via Kardex of any significant weight loss, as well as the physician. Review of the facility Job Description for Clinical Dietician revealed the dietician represents the department by attending and participating in all resident related meetings including Morning meeting, Clinical meeting, Resident Care Conferences, and Quality Improvement. During an interview on March 14, 2013 at 9:45 a.m., the DON stated she was aware of a gradual weight loss in Resident 1. She stated the Dietician is responsible for notifying the Physician, and she was not sure if that was done. During an interview on March 14, 2013 at 10:15 a.m., the NHA stated she was not aware of the significant weight loss until the survey process. She stated that weight loss and nutrition are not discussed during Clinical Rounds and the Dietician does not attend clinical rounds and care plan conferences. The NHA stated if the Dietician wrote interventions she wanted to implement, she did not implement them. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12 9(d)(1)(5) Nursing services. 28 Pa. Code: 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 211.6(d) Dietary services. 28 Pa. Code 211.10(a)(c) Resident care policies.