Every finding on record at Transitional Care Unit at Nazareth Hospital

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure the privacy and dignity for a resident with an indwelling foley catheter (tubing inserted into the bladder to drain urine) for one of three residents reviewed for catheters (Resident R34). Findings include: Review of facility policy Patient Privacy, Dignity & Confidentiality, dated 2019, revealed all staff members have a duty to ensure that the privacy and dignity of all service residents are respected. Patients have the right to be treated with dignity at all times and have their modesty protected. Review of Resident R34's clinical record revealed Resident R34 was admitted to the facility on [DATE] with a diagnosis of abscess of sacrum (localized collection of pus), Parkison's disease (progressive neurological disorder that primary affects movement), and acute kidney injury (kidneys suddenly lose ability to filter waste products from the blood). Observation on February 09, 2026 at 10:06 a.m. revealed Resident R34's room door open and the resident lying in bed with his/her catheter bag exposed and secured to his/her right side of bed. The catheter bag lacked a privacy cover and the catheter bag and its contents were visible to individuals walking by Resident R34's room. Interview on February 09, 2026 at approximately 10:15 a.m. with Employee E3, Licensed Practical Nurse, confirmed Resident R34's urinary catheter bag should have a privacy cover in place. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that advanced directives/code status were in place for two of 11 clinical records reviewed (Resident R110 and Resident R111). Findings include: Review of facility policy on Advance Directive and Healthcare Agents and Representatives revealed that under section Purpose: The purpose of this policy is to ensure that [NAME] Hospital physicians and colleagues respect the health care decisions of its patients and comply with the requirement of Pennsylvania law governing Living Wills. Under section Policy: [NAME] Hospital will comply with the Living Will of a patient. Under section Admission Procedure: Upon admission to [NAME] Hospital facility, the patient shall be informed of the right to execute an Advance Health Care Directives. The patient access representative will ask the patient if the patient has executed a living will/advance health care directive and if the patient has designated someone to be the patient's health care agent. The response will be a mandatory field within the electronic medical record. (EMR). If a patient has a living will/advance health care directives, a copy will be requested and scanned directly into the EMR. Review of Resident R110's clinical record revealed that Resident R110 was admitted to the facility on [DATE]. Further review of Resident R110's clinical record revealed that there was no advance directive in place and there no code status indicated Resident R110's clinical record. Review of Resident R110's physician orders revealed no order for advance directives or code status. Further review of Resident R110's clinical record revealed no documented evidence that advance directives was discussed with the resident. Interview with Resident R110 conducted on [DATE], at 2:52 p.m. with her sister acting as sign language interpreter revealed that she has a living will and wants one of the measures to be Do Not Resucitate. Interview with the Social Worker Employee E3 conducted on [DATE], at 3:05 p.m. revealed that she was aware of Resident R110's Advance Directives. Further Employee E3 also revealed that she was waiting for the physician to order the resident's advance directives and that only the physician can order the advance directives, and that code status will not reflect in Resident R110's clinical record until the physician orders it. Interview with the DON (Director of Nursing) Employee E2 conducted on [DATE], at 3:10 p.m. confirmed that there was no advance directive in place in Resident R110's clinical record. Further DON Employee E2 also confirmed that the physician has not ordered the advanced directive and that until the physician enters the order for Resident R110's Advance Directives, it will not be reflected in Resident R110's clinical record. Further interview with DON Employee E2 revealed that without the advance directive or without the code status indicated in the resident's clinical record, the resident will be considered a full code. Review of Resident R111's clinical record revealed that Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's physician's orders revealed that a No CPR (Cardiopulmonary Resuscitation) and Do Not Intubate was ordered on [DATE], nine days after Resident R111's admission to the facility. Further review of Resident R111's clinical record revealed no documented evidence that advance directives was discussed with the resident from admission until [DATE]. Interview with the DON (Director of Nursing) Employee E2 conducted on [DATE], at 03:10 PM confirmed that there was no advance directive in place in Resident R111's clinical record until [DATE], nine days after Resident R111 was admitted to the facility. Further DON Employee E2 also confirmed that there was no code status indicated in Resident R111's clinical record until the physician entered the order for No CPR (Cardiopulmonary Resuscitation) and Do Not Intubate on [DATE]. Further interview with DON Employee E2 revealed that without the advance directive or without the code status indicated in the resident's clinical record, the resident will be considered a full code. 28 Pa Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of facility policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R61 and Resident R108) Findings include: Revie of facility policy on medication administration revealed that the policy did not address hand washing and other infection control subjects. Review of facility policy on Hand Hygiene revealed that under section Purpose: To assure proper hand hygiene practices are utilized by employees during all activities including patient care, and to prevent transmission of infectious pathogens. Hand hygiene helps to physical remove infectious from hands. Hands can also be decontaminated using waterless alcohol hand sanitizer. Under section Policy: It is the policy of [NAME] Hospital to decrease the risk for transmission of nosocomial pathogens that may be carried on the hands of healthcare workers. Under section Procedure: #3 Hand hygiene will be performed at the following times and as necessary: #a. Before and after entering a patient's room #b. Before and after direct patient contact. #c. Before donning gloves. #d. After removing gloves.#g. after contact with objects (including equipment) located in a patient's environment. Medication administration observation conducted on March 19, 2025, at 8:50 a.m. with Licensed nurse Employee E4 revealed that during medication administration for Resident R61, Employee E4 was observed wearing gloves. Further observstion revealed that Employee E4 proceeded to administer Resident R108's oral medications with the gloves on. Further observation revealed that Employee E4 was touching Resident R61's bed side table with the same gloves and proceeded to administer Resident R61 with an eye ointment without changing gloves. Medication administration observation conducted on March 19, 2025, at 9:38 a.m. with licensed nurse Employee E5 revealed that during medication administration for Resident R108, Employee E5 was observed wearing gloves Further observation revealed that Employee E5 proceeded to administer Resident R108's oral medications with the gloves on. Further, Employee E5 proceeded to apply Resident R108's Nystatin powder 100,00 units to Resident r108's groin without changing gloves. After applying the Nystatin powder 100,00 units to Resident R108's groin, Employee E5 proceeded to pull Resident R108's pajamas up, touched the bed, adjusted the bed controls, touched the overhead table, removed resident R108's heel booties, touched the bed controls to adjust the height of the bed and to elevate the head of bed without changing gloves or washing hands. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on staff interviews and the review of clinical records, it was determined that the facility failed to clarify a physician's order related to daily weights for one out of 11 residents reviewed (Resident R61). Findings include: Review of the facility policy, Weights, with a review date of August 2019 indicted that the purpose of the policy is to monitor weight gain or loss. The policy also indicated that nursing will notify the physician or any weight gain of 2 or more pounds in one day, and the dietician of any weight loss. Review of the guidelines that the facility follows for the managemement of heart failure, 22 AHA/ACC/HFSA Guideline for the Management of Heart Failure indicated that the facility's disease management programs may compromise education, self-management, medication optimization, device management, weight monitoring, exercise and dietary advices . Review of Resident R61's nursing note dated March 13, 2025 at 11:54 a.m. indicated that the resident was admitted in to the facility with diagnosis that included the following: Hypoxia (low levels of oxygen), and Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of the resident's March 2025 physician orders included a physician's order for the resident to have daily weights. Review of the resident's weights obtained by the facility included the following weights: March 13, 2025 -177lbs at 6:31 p.m. March 14, 2025 -180lbs at 6:10 a.m. March 14, 2025 -180lbs at 2:53 p.m. March 15, 2025 -183lbs at 6:00 a.m. March 16, 2025 -184lbs at 6:00 a.m. March 16 2025 -185lbs at 11:00 a.m. March 17, 2025 -185lbs 5:35 a.m. March 18, 2025 -185lbs at 5:37 a.m. March 19, 2025 -187lbs at 6:25 a.m. March 20, 2025 -188lbs at 6:00 a.m. During an interview with the Director of Nursing (DON) on March 20, 2025 at 12:30 p.m. the DON reported that the rationale behind the physician's order for daily weights was related to his diagnosis of CHF. The American Heart Association's article, Managing Heart Failure Symptoms, indicated that many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. This weight gain may be due to retaining fluids since the heart is not functioning properly. It's a good idea to track your weight and check in with your health care professional if you notice sudden changes and to make sure that you know the amount of weight gain your health care professional considers to be a problem for you. Review of the resident's daily weights indicated that from March 13, 2025 through March 14, 2025 Resident R61 gained 3lbs. Review of the resident's daily weights indicated that from March 14, 2025 through March 15, 2025 Resident R61 gained an additional 3lbs. Review of the resident's daily weights indicated that from March 15, 2025 through March 16, 2025 Resident R61 gained an additional 1-2lbs Review of the resident's daily weights indicated that from March 16, 2025 through March 20, 2025, the resident gained an addition 4 lbs. Continued review of the resident's daily weight scheduled indicated that from the date of the resident's admission (March 13, 2025) through March 20, 2025, Resident R61 gained a total of 11lbs in an 8 day period. Review of the physician's order did not indicate when staff should alert the physician to weight gain. Continued review of the resident's physician notes did not show evidence that the resident's attending physician,was notified by nursing staff of the resident's initial weight gain, and any other weight gain thereafter. During an interview with the Director of Nursing (DON) on March 20, 2025 at 1:15 p.m. the DON reported that that all resident weights are discussed in morning meeting, but could not provide any evidence that the facility notified the physician of the resident's weight gain totaling 11 pounds within an 8 day period. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nusing services

Based on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain a peripheral inserted central catheter (PICC) consistent with professional standards of practice for one of one resident with a PICC line. (Resident R4) Findings include: Review of facility policy on Maintenance of Central Venous Catheters (CVC) revealed that under section Purpose: intravenous therapy for the administration of blood products, fluids, and parenteral nutrition, as well as for hemodynamic monitoring is an essential part of medical practice. The following policy pertains to all central venous catheters (CVC) utilized at [NAME] Health Mid-Atlantic region, including PICC. Under section Maintenance of the Catheter Site, # C. The insertion site will be evaluated every shift for evidence of complications. Assessments include gentle palpation of the site through the intact dressing to discern tenderness and visual inspection of insertion site through the transparent dressing. Observation conducted on March 17, 2025, at 10:35a.m. during the tour of the unit revealed that Resident R4 was in bed awake. Further an intravenoues (IV) line was observed on the inner side of Resident R4's left upper arm. Interview with Resident R4 conducted at the time of the observation revealed that he gets antibiotics and that the nurses give him the antibiotic using the intravenous line on his left arm. Review of Resident R4's clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Further review of Resident R4's clinical record revealed an order dated March 7, 2025, for Ceftriaxone (Rocephine) IV syringe 2 gm IV 400 ml/hr. every 12 hours. Interview with DON (Director of Nursing) Employee E2 conducted on March 18, 2025, at 12:56 p.m. revealed that the facility follows the policy for central venous catheters in caring for all PICC (peripherally inserted central catheter-a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest, near the heart. It is used to provide access for administering medications, fluids and nutrition.). Further DON Employee E2 also revealed that PICC lines are measured by the nurse who administers the antibiotic to ensure proper placement. Review of Resident R4's clinical record revealed that there was no documented evidence that Resident R4's PICC line site was evaluated every shift or on a regular basis and there was no documented evidence that the PICC line length was measured at any time from Resident R7's admission on March 7, 2025, up to March 17, 2025, to ascertain proper placement of the PICC line. Interview with DON Employee E2 confirmed that Resident R4's PICC line was not measured during his stay at the facility. Further DON Employee E2 revealed that PICC line length should be measured before administering an IV ABT (intra-venous antibiotic therapy) via PICC line. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical records review, it was determined the facility did not develop a person centered baseline care plan for two of five resident clinical records reviewed. (Residents R3 and R116) Findings include: Review of facility policy titled Care Plan Policy last revised August 2012 revealed The transitional care unit at [NAME] Hospital will develop a comprehensive care plan for each resident that includes measurable objectives a timetables, to meet a residents medical, nursing and mental , and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], to receive rehabilitation services for ambulatory disfunction (a condition that make it difficult to walk). Continued review of the clinical record revealed that Resident R3 had the diagnoses of urinary tract infection, ambulatory disfunction (a condition that makes it difficult to walk), shortness of breath, kidney disease, prostate cancer. Review of Resident R3's July 2023 physician orders revealed an order for an interdewelling urinary catheter care for the resident due to a super pubic catheter (a flexible tube that is surgically inserted to drain urine from the bladder). Further review of Resident R3's clinical record revealed a care plan initiated July 17, 2023. The care plan identified resident's needs for fall precaution and interdwelling catheter maintenance. Continued review of the resident's care plan revealed that there were no interventions developed related to fall precautions. Further the care plan stated that nursing staff will change foley catheter and urinary bag as needed and nursing staff will provide foley catheter care at every shift as needed. The resident did not have a foley catheter but am interdwelling catheter. The facility failed to develop interventions for an interdwelling catheter. Review of Resident R116 's clinical record revealed that Resident R116 was admitted to the facility on [DATE] with diagnosis of papillary carcinoma pancytopenia palate cancer and pressure injury on his left buttock. Further review of Resident R116's clinical record revealed a care plan initiated July 12, 2023 for interdwelling catheter maintenance, with the goal for the resident to have no complications for the interdwelling catheter. There were no other interventions developed to achieve the goal. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on a review of facility documents and interviews with staff, it was determined that the facility failed to provide completed documentation and information as required within the appropriate time frames. Findings include: An entrance conference was held on July 24, 2023, at 9:15 a.m. the entrance conference worksheet was provided to the Director of Nursing informing the facility of needed documents and their expected time frames for delivery. The list of documents included but was not limited to, the wifi access and patient records access, to be delivered immediately. On July 24, 2023, at 12:10 p.m. another request was made for patient record access. Interview with Director of Nursing at the time stated that the requests for access was made but has been denied. Director of Nursing was waiting for IT (information technology) to respond to the requests. On July 25, 2023, at 9:00 a.m., surveyors were given computers to be able to access they system but still surveyors were unable to gain access to the facility program. At 10:33 a.m., surveyors were given access and assisted into the facility patient record program. The information surveyors received was given by facility employee navigating the patient record program. On July 26, 2023 at 11:10 a.m., it was learned that the surveyors did not have full access of all residents electronic medical records. An exit conference was held on July 27, 2023, at 2:00 p.m. at this time, surveyors had still did not have full access and it was confirmed that surveyors were not granted full access to all records. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, facility policy review, and interview with staff, it was determined that the facility failed to ensure the security of a medication cart for one of one cart observed. Findings include: Review of facility policy titled Administering Medications, dated February 15, 2023 revealed never leave poured or prepared medications unsupervised. Observations conducted on July 24, 2023 at 9:00 a.m. revealed that a medication cart stationed on the second floor was unlocked and unattended for a period of 7 minutes not in view of licensed nurse, Employee E24. At 9:08 a.m., Licensed nurse, Employee E24, approached the cart. When the surveyor asked why the cart was unlocked, Employee E24 stated, she was tending to a resident on isolation and could not bring the cart in the room. Interview with the Nursing Home Administrator, and the Director of Nursing, Employee E2 on July 25, 2023, at 12:30 p.m. confirmed that medication cart should be locked at all times when unattended. 29 Pa. Code 211.12(c) Nursing services 29 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, interviews with staff and policy and procedure review, it was determined for one of two closed resident records, the facility failed to ensure a comprehensive, orderly, systematic and coordinated discharge to the community. (Resident R9) Findings include: Review of Resident R9's closed clinical record revealed that the resident was admitted to the facility on [DATE] for rehabilitation. On May 8, 2023 the physician's progress note indicated that the resident was requesting to be discharge. On May 9, 2023 the nursing staff documented in the clinical record that Resident R9 left the facility at 8:05 p.m., with a family member to return home. The resident was documented as advised to continue Nexium 40 milligrams (mg) twice daily to treat acid reflux, Ibuprofen 800 mg three times a day and as needed for pain, Carisoprodol 350 mg daily as needed for muscle spasm, Calcitrol 25 mg daily (a vitamin supplement) and Lisinopril 20 mg daily to treat high blood pressure. The physician indicated that the resident was advised to keep a log of her blood pressure at home. The resident was also advised to monitor her systolic number of her blood pressure and consider taking a lower dose if the blood pressure was less than 110. There was no documented evidence to indicate that Resident R9 had these medications were called into the local pharmacy for the continuation of the resident's care at home. There was no documentation to indicate that Resident R9 had a device to check her blood pressure daily. There was no documentation to indicate that the resident was supplied the family practice physician's contact information for laboratory studies (basal metabolic profile, magnesium level) that were advised for completion after discharge. The clinical record lacked documentation to indicate that Resident R9 was discharge to the community with her personal belongings. Interview with the Director of Nursing, Employee E2, on July 27, 2023 at 10:00 a.m., confirmed that the facility failed to provide documentation to indicate that arrangements were made for Resident R9 to receive home care needs (medications, medical equipment, physican's contact information) after discharge. Interview with the Director of Social Services, Employee E3, on July 27, 2023 at 10:30 a.m., confirmed that there was no documented accounting of Resident R9's personal belongings upon admission or at time of discharge. 28 Pa. Code 211.12(c)Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record reviews, and staff interview, it was determined that the facility failed to ensure that physician orders were follow related to medications for diabetes mellitus and hypotension for two of six residents reviewed. (Residents R61 and R70) Findings include: Clinical record review revealed that Resident R70 was admitted to the facility on [DATE]. The physician's assessment dated [DATE] indicated that the resident had a diagnosis of diabetes mellitus (a metabolic disorder in which the body has high blood glucose levels for prolonged periods of time, that was caused by an inadequate production of insulin). Clinical record review revealed that Resident R70 had physician' orders for insulin (Lispro Humalog); which was a fast acting insulin used to control high blood glucose. The physician directed the nursing staff to monitor Resident R70's blood glucose three times daily with meals. The physician orders also included directions for the nursing staff to treat hypoglycemia (low blood glucose). The physician indicated that for a blood glucose reading less than 54 mg/dl; directions were for the nursing staff to provide 30 grams of glucose (1 cup of apple juice/1 cup cranberry juice) to Resident R70. On July 24, 2023 the nursing staff documented a low blood glucose reading of 44 . There was no documentation to indicate that the nurse provided the 30 grams of glucose for Resident R70 as ordered by the physician on July 24, 2023. Interview with the Director of Nursing, Employee E2, on July 26, 2023 at 10:00 a.m., confirmed the lack of documentation to indicate that the physician's orders were followed directing the nursing staff to give 30 grams of glucose to Resident R70 for a low blood glucose of 44 obtained on July 24, 2023. Clinical record review for Resident R61 revealed that this resident had a diagnosis of heart failure. The physician had prescribed medication (Carvedilol) for this resident's cardiac issues. The Carvedilol medication was ordered two times a day with meals and specific instructions were indicated for its' administration by the nursing staff. The instructions were to obtain a blood pressure reading (was the pressure of the blood pushing against the walls of the arteries) and determine if the systolic blood pressure was below 105.) The physician had directed the nursing staff to hold the medication if the systolic blood pressure was below 105 or hypotension (low blood pressure). On July 19, 2023 the nursing staff documented at 9:00 a.m., that a blood pressure reading of 101/64 for resident R61. The medication Carvedilol was administered and not held as directed. On July 19, 2023 the medication, Carvedilol was administered at 5:00 p.m., to Resident R61; however there was no blood pressure obtained by the nursing staff. On July 21, 2023 at 9:00 a.m., Resident R61 had a blood pressure of 90/53. The medication, Carvedilol was given; despite physician's orders to hold the medication for a systolic reading less than 105. On July 21, 2023 at 4:00 p.m., a blood pressure reading of 98/61 was recorded by the nursing staff. The nursing staff documented that the medication, Caredilol was given to Resident R61. The nursing staff was directed to hold the medication for a systolic blood pressure reading of less than 105. On July 24, 2023 at 9:00 a.m., the nursing staff documented a blood pressure of 96/52. The medication, Carvedilol was administrated to Resident R61 and not held as directed by the physician. On July 24, 2023 at 5:00 p.m., the blood pressure of 94/54 was obtained for Resident R61. The medication, Carvedilol was administered to Resident R61 and was not held according to the physician's orders. The above findings were confirmed on July 26, 2023 at 9:30 a.m., with the Director of Nursing, Employee E2. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services

Based on observation, clinical record review and interviews with staff, it was determined that the facility did not maintain respiratory equipment according to professional standards of practice for two of two residents reviewed in oxygen therapy (Resident R3 and Resident R112). Findings include: Observations conducted on July 25, 2023, at 10:56 a.m. revealed that Resident R3 was receiving supplemental oxygen via nasal cannula and the tubing was undated. Observations conducted on July 25, 2023, at 11:15 a.m. revealed that Resident R112 was receiving supplemental oxygen via nasal cannula and the tubing was undated. Interview with Licensed nurse, Employee E11 on July 26, 2023 at 2:05 p.m. confirmed that the tubing has not been dated. Interview with Director of nursing on July 27, 2023 at 2:40 p.m. revealed that the tubing is changed every Sunday and should be dated. 28 Pa. Code 211.12(c) Nursing services 29 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of facility policy and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, for one of one medication storage room observed. Findings include: Review of the Policy and Procedure on Storage of Pharmaceuticals, dated December 21, 2020, stated: A medication refrigerator temperature should be maintained between 36 F and 46 F. The temperatures are logged on calendar. Observation of the medication storage room on September 26, 2022, at 2:05 p.m., revealed the medication-storage-refrigerator had various vaccines and antibiotic solutions kept inside, but the refrigerator temperature was 47 degrees Fahrenheit. Further review of the temperature log of the medication-storage-refrigerator indicated there were gaps in the temperature log for the months of May 2022, June 2022, July 2022, August 2022, and September 2022 where no temperature was recorded. Interview with the Registered Nurse, Employee E5, at the time of the finding, confirmed that the refrigerator temperature should be between 36 degrees Fahrenheit and 46 Fahrenheit, and that there should not be any gaps in the refrigerator temperature log. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.9(g)(h) Pharmacy services 28 Pa Code 211.12(c) Nursing services 28 Pa 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the use personal protective equipment for one of one resident observed on transmission based precautions. (Resident 57) Findings include: Review of facility policy on 'Standard Precautions, Transmission Based Isolation Precautions and Neutropenic Precautions, dated March 1, 2022, indicated its purpose as follows: To provide safe and effective care and to prevent hospital acquired infection among patients, staff, and visitors. Minimizing the spread of contagious diseases/conditions and multidrug-resistant organisms ([CONDITION(S)]) within the facility by instituting appropriate transmission-based isolation precautions. The policy further specified that, the institution shall abide by current recommendations pertaining to transmission-based isolation precautions, as set forth by the Centers for Disease Control and Prevention (CDC). Under General Procedures of the policy, it was specified; Hand Hygiene should be performed before and after entering patient rooms, before and after touching patients, before and after touching patients' surroundings. The policy detailed about the procedure for using Personal Protective Equipment (PPE) and described as follows: Gowns-Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. Use of gowns reduces the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments. Gowns are single use and are discarded into the appropriate waste receptacle when leaving the patient's room. Gloves-Gloves should be used only once and then discarded into the appropriate waste receptacle when leaving patient's room. Supplies of gloves are readily available in patient rooms and patient care areas. Masks, Respiratory Protection, Eye Protection, Face Shields- Various types of masks, goggles and face shields are worn alone or in combination to provide barrier protection. A mask that covers the nose and mouth, with goggles or a face shield, is worn by hospital personnel during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions in order to provide protection of the mucous membranes (eyes, nose, and mouth) from blood or body fluid exposure. Observation conducted on September 22, 2022, at 10:07 a.m. revealed a Physician, Employee E12, entering Resident 57's room without wearing gloves, facial screen/goggle, and gown . The observation was confirmed with the Director of Nursing. Observation on September 22, 2022, at 10:11 a.m. revealed a Physical Therapist, Employee E13, entered Resident 57's room without wearing gloves, facial screen/goggle, and gown . The observation was confirmed with Licensed nurse, Employee E13. Observation conducted on September 26, 2022, at 10:03 a.m. revealed a signage near the entrance of Resident 57's room which indicated Transmission Based Precaution. On September 22, 2022, at 10:04 a.m., the Respiratory Therapist, Employee E11, was observed entering Resident room [ROOM NUMBER], without wearing gloves, facial screen/goggle, and gown. The observation was confirmed with the Director of Nursing. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code. 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to maintain a homelike environment for the entire nursing unit (one floor within the hospital). Findings include: During the initial tour of the facility on (MONTH) 3, 2019 and all remaining days of the survey, (September 4, 5 and 6, 2019), at various times revealed the following observations: Resident room [ROOM NUMBER] had green duct tape across the floor at the door way from the all way. Resident room [ROOM NUMBER] had an area measuring three feet by 10 inches, with blue duct tape on the floor and the floor area in the left corner was heavily stained with brown dirt. The room had a strong odor and paint peeling inside of window on the left side of the floor at the base of the bed, appeared to be bubbled up. The wall area at the head of the bed was noted with holes and the floor was marred around the wardrobe. Resident room [ROOM NUMBER] holes were observed in the wall at the head of both beds and the entire floor was dirty. Resident room [ROOM NUMBER] (door) the wall at the head of the bed had holes, the entire floor was dirty and worn. The wall near the window had a two foot by two foot area that had been plastered but was not sanded and painted. The entire facility (one nursing unit located within the hospital), was observed to have walls, (resident rooms, care areas and nursing care unit hall ways), that were dull in color and all floor areas were observed to be well worn and permanently stained. Interview with the Nursing Home Adminsitrator on (MONTH) 6, 2019, at 2:45 p.m. confirmed that the facility environment did not enhance a homelike environment. The facility failed to maintain an environment that was homelike. 28 Pa Code 201.18(b)(1) Management Previously cited 11/6/18 28 Pa Code 201.18(b)(3) Management Previously cited 11/6/18 28 Pa code 207.2(a) Adminstrator's responsibility

Based on observation, review of clinical records, facility documentation and review of policy and procedure and staff interview, it was determined, the facility failed to adequately assess and monitor the need for bed rails for nine of 15 residents reviewed (R40, R41, R35, R21, R43, R42, R28, R20 and R32). Findings include: Review of facility policy, Restraint Free on TCU, dated (MONTH) (YEAR), revealed that, Education is given to the patient and their family on the use of side rails for transfers and mobility, but not as a restraint. Interview on (MONTH) 6, 2019, at 10:00 a.m., the Nursing Home Administrator stated that there was no specific policy for bedrails. Observation on (MONTH) 3, 2019, at 3:39 p.m., Resident R32 was resting in his bed. Three of his bedrails (two upper and one lower) were observed to be up. Interview at the time of the observation, Resident R32 stated that the bed was like that when he came in and that he did not ask to have his bedrails up. Continued observation on (MONTH) 4, 2019 at 8:09 a.m. again revealed Resident R32 resting in bed with the same three bedrails in the up position. Clinical record review for Resident R32 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 30, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident care plans revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Observations of Residents R40, R41, R35, R21, R43, R42, R20 and R28, during the initial tour of the nursing unit, on (MONTH) 3, 2019, from 11:40 a.m. - 4:20 p.m. revealed, R40, R41, R35, R21, R43, R20 and R28, were lying in there beds, with three or more quarter rails in the up potion. On (MONTH) 4, 2019, between, 8:15 a.m. - 2:00 p.m., revealed these same seven residents, (Residents R40, R41, R35, R21, R43, R42, R20 and R28), were observed again lying in there beds, with three or more quarter rails in the up position. Observation with Employee's E3, Licensed nurse and E5, Certified Nurse Aide, on (MONTH) 4, 2019, between 8:15 a.m. - 2:00 p.m. confirmed individual observations of Residents R40, R41, R35, R21, R43, R42, R20 and R28, with three or more quarter bed rails in the up position. At the time of the confirmation interviews of the observations of the eight residents with the three or more quarter rails in the up position, revealed each of the residents were identified as alert, oriented and able to make there own decisions. Employee E3, further indicated, the three or more quarter rails being put in the up position while a resident is in bed, Long time facility practice, to keep residents from falling. Clinical record review for Resident R40 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 21, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R41 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 12, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R35 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 29, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R21 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 28, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R43 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 30, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R42 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 26, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Clinical record review for Resident R28 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 20, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. An individual interview conducted with Resident R20, on (MONTH) 3, 2019, at 11:50 a.m. revealed, Did not ask for any of the rails, the staff use all four quarter rails at night so residents do not fall out of bed. An interview with the Director of Nursing on (MONTH) 4, 2019, at 1:20 p.m. confirmed that Resident R20, was completely alert, oriented able to make decisions and further confirmed observation of Resdient R20's four quarter rails in the up position. Clinical record review for Resident R20 revealed a Consent for the Use of Restraints, dated and signed by the resident on (MONTH) 20, 2019. Other than the signature section, the rest of the form was not filled in. There was no indication that the resident requested or received education related to siderail use or that he was assessed for safe and proper bedrail usage. Review of the resident current care plan revealed that no care plan was developed to indicate of the resident had a preference to use bedrails. Interview on (MONTH) 5, 2019, at 9:30 a.m., the Director of Nursing confirmed that none of the nine residents identified, (R40, R41, R35, R21, R43, R42, R28, R20 and R32), had care plans related to bedrail usage or preference and that no formal assessment was completed related to bedrails (proper fit, proper usage, entrapment risks, etc.) The facility failed to ensure residents that were adequately assessed and monitored that were using multiple quarter side rails. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/6/18 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 11/6/18

Based on observation, clinical record review and staff interview, it was determined that the facility failed to developed comprehensive care plans for the use of an device to prevent elopment, for the risk for elopment, falls and for a renal diet for four of 15 residents reviewed. (Resident R30, R32, R38, R46) Findings include: Observation on (MONTH) 3, 2019, at 3:10 p.m. revealed that Resident R38 had a wanderguard device (a device that alert facility staff when a resident is trying to exit a unit or building. The device also may automatically lock the doors to prevent the resident from exiting) on his right wrist. Interview conducted with Resident R38 at the time of the observation, revealed that he was unsure why he had the device on, that he was never asked about it and that it was just put on him. Resident R38 also admitted that he was confused his first night at the facility. Clinical record review for Resident R38 revealed an Elopement Assessment, dated (MONTH) 27, 2019, which indicated that the resident was at risk for elopement. Review of Resident R38 nurses' notes dated (MONTH) 27, 2019 at 7:59 p.m., indicated that the resident was admitted to the facility from the hospital. The resident was alert and oriented to person, place and time, and that he was emotional and anxious. Further review of nursing notes revealed a note dated (MONTH) 28, 2019, at 1:04 a.m., indicated that Resident R38 got confused tonight and thought that he was still at the hospital. Review of facility documentation received on (MONTH) 3, 2019, at approximately 3:00 p.m., by the Director of Nursing (DON) revealed that Resident R38 was identified by the facility as having a wanderguard device in place. Review of Resident R38 current care plan revealed no care plan for the use of a wanderguard device on Resident R38. Interview on (MONTH) 5, 2019, at 8:30 a.m., the DON stated that she was not aware that Resident R38 was identified as an elopement risk and confirmed that there were was no care plan developed for the resident related to the wanderguard device. Clinical record review for Resident R30 revealed an Elopement Assessment, dated (MONTH) 26, 2019, which indicated that the resident was at risk for elopement and that he refused to wear a wanderguard. Continued record review revealed that there was no care plan for Resident R30 related to the resident being identified as an elopement risk. Interview on (MONTH) 6, 2019, at 11:42 a.m., the DON stated that she was not aware that Resident R30 was identified as an elopement risk and confirmed that there was no care plans developed for the resident related to being an elopement risk. The DON was unable to explain why the resident was identified as an elopement risk and confirmed that the nurse who completed the assessment did not pass on in report that the resident had been identified as being at risk for elopement. Review of Resident R32's (MONTH) 2019 physician's orders [REDACTED]. Review of care plan meeting notes, dated (MONTH) 4, 2019, revealed that the resident was on a renal diet, that the resident reported eating less than 50% of meals, and that the resident would like to try Nepro (a nutritional supplement for people on [MEDICAL TREATMENT]). Review of Resident R32's baseline care plan, dated (MONTH) 30, 2019, indicated that the resident was on a cardiac diet. Review of the resident's End Stage [MEDICAL CONDITION] care plan, dated (MONTH) 28, 2019, also indicated that Resident R32 was on a cardiac diet. Review of Resident R32's Nutrition care plan, dated initiated (MONTH) 31, 2019 and updated (MONTH) 3, 2019, revealed that the resident was on a cardiac diet. There was no indication on any of the resident's care plans that he was ordered a renal diet, that he had poor meal intakes, or that he wanted to try a nutritional supplement. Follow-up interview on (MONTH) 6, 2019 at approximately 1:00 p.m., the DON confirmed that Resident R32 ' s care plan did not reflect that he was on a renal diet. Clinical record review for Resident R46 revealed an admitted (MONTH) 24, 2019 which indicated a [DIAGNOSES REDACTED]. Continued review of R46's clinical record revealed at the time of admission to the facility R46, was identified as a high risk of falls. Further review of the clinical record revealed that Resident R46 had a fall in the bathroom on (MONTH) 2, 2019. Further review of the clinical record revealed that a baseline care plan was developed on (MONTH) 24, 2019 with interventions to asses level of risk for falls. There was no care plan developed after the resident was assessed at high risk for falls. The facility failed to developed comprehensive care plan for Residents R30, R32, R46 and R38. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records Previously cited 11/6/18 28 Pa. Code 211.11(a)(d)(e) Resident care plan Previously cited 11/6/18 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 11/6/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/6/18

Based on closed clinical record review and staff interview, it was determined the facility failed to develop a discharge care plan for one of two closed records reviewed (Resident R45). Findings include: Based on review of Resident R45's clinical record, revealed an admission physician order [REDACTED]. Review of the resident's admission Minimum Data Set (MDS-periodic assessment of resident's needs) dated (MONTH) 16, 2019, indicated in section, Q0400, Discharge Planning - Is there an active discharge plan in place for resident to return to community, was indicated to be marked with a yes. Continued review of the admission MDS, indicated in section, Q0600 Referral - Has a referral been made to the local contact agency? was indicated to be marked with a yes. Review of Resident R45's entire care plan revealed that there was no care plan for discharge planning. An interview with the Director of Nursing, on (MONTH) 6, 2019, at 9:10 a.m. confirmed that no discharge care plan was developed at the time of admission for Resident R45, at the time of admission to the facility on (MONTH) 16, 2019, The facility failed to develop a discharge care plan for Resident R45. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/6/18 28 Pa. Code 201.18(b)(3) Management Previously cited 11/6/18 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records Previously cited 11/6/18 28 Pa. Code 211.11(a)(d)(e) Resident care plan Previously cited 11/6/18 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 11/6/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/6/18

Based on observation, review of facility policies and review of clinical records and interviews with residents and staff, it was determined that the facility failed to ensure each resident's dignity was maintained regarding the use of a wanderguard device ( alram bracelet) for four of 19 residents reviewed (Residents R36, R28, R40 and R23). Findings include: Review of facility policy, Elopement Risk Assessment, dated last revised (MONTH) 1, 2019, revealed that, All residents will be banded with elevator alarm bracelet. During the initial tour of the facility on (MONTH) 3, 2019, from 11:15 a.m. - 4:30 p.m. at various times, Residents R23, R28 and R40, revealed during individual interviews, that they did not like having on their wrist, Alarm bracelet. Resident R40, indicated the bracelet made her feel like she was a, Prisoner. An interview with the Director of Nursing on (MONTH) 4, 2019, at 1:50 p.m. confirmed that Residents R23, R28 and R40, were all completely alert, oriented and did not display behaviors such as wondering, exit seeking and/or were confused in any sense. Review of facility documentation received on (MONTH) 3, 2019, at 3:00 p.m., provided by the Director of Nursing, indicated, Resident's R23, R28 and R40, were identified by the facility has having a wanderguard device in place. Further review of the documentation, did not indicate that the three resident's (R23, R28 and R40), were identified as elopement risks from the nursing unit. Interview with Director of Nursing on (MONTH) 5, 2019, at 1:30 p.m. confirmed that the three residents, (R23, R28 and R40), had wanderguard devices on their body, and they did not display any behaviors to indicate a risk of elopement from the nursing unit. Observation on (MONTH) 3, 2019, at 1:00 p.m. of Resident R36 revealed that the resident was wearing a wanderguard device on her right wrist. Interview at the time of the observation, with Resident R36' s family member stated that she did not know what the device was for or why the resident was wearing it. The family member further stated that the resident was unable to self-propel (mover herself forward) in a wheelchair or walk without assistance. Clinical record review for Resident R36 revealed an elopement assessment, dated (MONTH) 26, 2019, which indicated that the resident was not at risk for elopement. Review of the resident' s baseline care plan dated (MONTH) 28, 2019, revealed that Resident R36 needed the assistance of one staff person for transfers, walking and locomotion. Review of physical and occupational therapy notes from (MONTH) 27, 2019, through (MONTH) 5, 2019, revealed that the resident frequently required many rest breaks due to fatigue and weakness, that she required encouragement to participate with therapy and to stay awake, and continued to demonstrate decreased endurance with ambulation. Review of nurses' notes revealed that there was no documentation of any exit-seeking behaviors for the resident. Continued record review revealed that there was no care plan nor physician orders [REDACTED]. Review of facility documentation received on (MONTH) 3, 2019, at approximately 3:00 p.m., by the Director of Nursing (DON) revealed that Resident R36 was identified by the facility as having a wanderguard device in place. Interview on (MONTH) 5, 2019 at 8:30 a.m., the Nursing Home Administrator (NHA) and the DON stated that all the residents are given or offered a wanderguard device upon admission to the facility, regardless of whether or not they are at risk for elopement. The facility failed to ensure each resident's dignity was maintained regarding the use of wanderguard devices. 28 Pa Code 201.29(j) Resident rights Previously cited 11/6/18 28 Pa Code 211.10(d) Resident care policies Previously cited 11/6/18

Based on clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that the resident' s wishes for Advance Directives (one's wishes on life sustaining medical or surgical treatment) was accurately reflected in the medical record for two of 19 residents reviewed (Residents R38 and R40). Findings include: Review of facility policy Advance Directives, dated last reviewed (MONTH) 19, 2019, revealed that Residents will be asked during the admission process if they have an Advance Directive. Clinical record review for Resident R38 revealed that the resident was assessed by Employee E3, Registered Nurse, on (MONTH) 27, 2019 at 7:17 p.m. for Advanced Directives. The nurse indicated that the resident's response was, I do not want CPR (cardiopulmonary resuscitation- a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth). Continued record review for Resident R38 revealed that there was no further indication in the record indicating the resident's wishes of not wanting CPR. Interview on (MONTH) 5, 2019, at 8:30 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that nurses do not enter a resident' s code status and that the nurse who wrote the above for Resident R38 should have called the physician. Clinical record review for Resident R40, revealed an admitted (MONTH) 21, 2019. Continued review of the clinical record revealed in the advance directive section of the clinical record indicated that at the time of admission, the Licensed nurse, completing the admission process for R40, indicated, R40 was confused and unsure of having an advance directive. Further review of the clinical record revealed that R40, had an identified responsible party to assist with decision making. Interview with Employee E6, Social Worker, on (MONTH) 8, 2019, at 12:30 p.m. confirmed that the admitting licensed nurse should have contacted R40's responsible party about advance directive wishes. The facility failed to ensure that the resident's wishes for Advance Directives was accurately reflected in the medical record. 28 Pa Code: 201.29(j) Resident rights Previously cited [DATE] 28 Pa Code: 211.10(d) Resident care policies Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited [DATE]

Based on clinical record review and staff interview, it was determined that baseline care plans were not developed for four of 15 clinical records reviewed within 48 hours of the a resident's admission (Residents R20, R40, R28 and R26). Findings include: Observation of Resident R26 on (MONTH) 4, 2019, at 10:00 a.m. revealed the resident lying in bed with two quarter rails up on the right side of the bed and one quarter rail up on the left side and with oxygen in place. At the time of the observation, Resident R26 indicated the quarter side rails enable her to repositioning herself in the bed. Interview with Employee E5, Certified Nurse Aide, at the time of the observation confirmed that she placed the three quarter rails in the up position while R26 was lying in the bed and had oxygen in place. Employee E5 further related that R26 is completely alert and oriented in making decisions. Review of the clinical record for Resident R26 revealed no Baseline care plan was available for review related to Resident R26 having raised bed rails and oxygen administration. Clinical record review for Resident R28 revealed an admission progress note dated (MONTH) 20, 2019, at 10:30 p.m. which indicted that Resident R28 was admitted to the facility with a foley catheter (hallow flexible tube placed into bladder to drain urine) in place. Continued review of the clinical record for Resident R28 revealed no Baseline care plan was developed related to R28 having a foley catheter. Observation of Resident R40 on (MONTH) 3, 2019, at 1:45 p.m. revealed the resident lying in bed with four quarter rails raised in the up position, two on both sides of the bed. Resident R40 was also observed with a wanderguard on her left wrist, which she indicated made her feel like a Prisoner. An interview with Employee E5, at the end of the observation, indicated that the four quarter rails were in the up position to assist R40, with repositioning in bed. Employee E5 indicated that Resident R40 was completely alert and oriented in decision making and could not explain why R40 was wearing a wanderguard on her left wrist. Clinical record review for Resident R40, revealed that the resident was admitted to the facility on (MONTH) 27, 2019. Continued review of the clinical record revealed no Baseline care plan was developed related to using four quarter siderails and the use of a wanderguard for Resident R40. Observation of Resident R20 on (MONTH) 4, 2019, at 3:00 p.m. revealed that R20 was lying in bed with two quarter rails up on the right side of the bed and one quarter rail up on the left side. At the time of the observation, R20, indicated the quarter side rails enable him to reposition himself in the bed. At the time of the observation an interview with Employee E5, Certified Nurse Aide, assigned to Resident R20 confirmed that she placed the three quarter rails in the up position before leaving R20's room while he was lying in the bed. Employee E5, further related that Resident R20 is completely alert and oriented in making decisions. At the time of the review of the clinical record for Resident R20, revealed no Baseline care plan was available for review related to R20, having bed rails in the up position. An interview with the Nursing Home Adminstrator and Director of Nursing on (MONTH) 5, 2019, at 2:00 p.m. indicated, that at the time a resident is admitted to the facility it is the responsibility of the licensed nurse completing the admission process to develop Baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records Previously cited 11/6/18 28 Pa. Code 211.11(a)(d)(e) Resident care plan Previously cited 11/6/18 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 11/6/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/6/18