Every finding on record at Transitions Healthcare Autumn Grove Care Center

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to consistently provide timely and necessary foot care for one of 19 residents reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], with diagnoses that included Cellulitis (a skin infection caused by bacteria, most commonly affecting the lower leg. Symptoms include swelling, pain, warmth, and redness), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn). Resident R1's physician's orders revealed an order dated 5/8/26, for Podiatry (branch of medical care focused on assessment, diagnosis, and treatment of conditions affecting the feet, ankles and lower extremities) Consult and Treat as needed and a consent for 360 Care - podiatry signed and dated by Resident R1 on 5/11/26. Resident R1's clinical record progress note dated 5/8/26, at 18:01 revealed Toenails are long, mycotic (fungal infections of the toenails that cause thickening, discoloration [yellow, brown, or white] brittle, crumbly or ragged edges, and separation or lifting of the nail from the nail bed. Possible pain or discomfort can result in severe cases), and in need of trim. Further review revealed progress notes entitled Skin and Wound dated 5/19/26, 5/27/26, 6/3/26, 6/10/26, 6/17/26, 6/24/26, 7/1/26, and 7/8/26, indicating Consultations (Recommendations) Podiatry - toenail care. Observation on 7/7/26, at 11:50 a.m. revealed Resident R1's toenails, on both feet, were thickened, yellowed, and extended past the tips of his/her toes, and the surface of the nails appeared rough and uneven. During an interview on 7/7/26, at the time of observation Resident R1 stated that he/she was unsure the last time he/she saw a podiatrist but knows it was before coming to the facility. Resident R1 then stated that he/she is receiving physical therapy so that he/she can walk and be able to go home, but that the condition of his/her toenails makes it painful and difficult to walk. Review of facility provided document entitled 360 Care Appointment Listing - Podiatry dated 7/1/26, lacked evidence of Resident R1 being scheduled to see the podiatrist for nail care. During an interview on 7/8/26, at 2:39 p.m. Nursing Home Administrator (NHA) revealed that if a resident signs consent for 360 Care, it is faxed to 360 Care, and the resident is put on their list to be seen during their next visit. During an interview on 7/9/26, at 10:30 a.m. NHA revealed 360 Care - podiatry provided services on 5/18/26, and 7/1/26, and that Resident R1 was missed on both of those visits, and he/she should have been seen and toenail care provided. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one of 57 rooms observed and for two of 57 bathrooms observed. Findings include: Facility policy dated 3/23/26, entitled Reporting Safety Hazards revealed the objective is to keep resident's environment as free of accidents and safety hazards as possible and that safety walkthrough will be done of each resident unit monthly. Observation of room [ROOM NUMBER] on 7/6/26, at 12:05 p.m. revealed four pieces of joined flooring tile with missing pieces measuring approximately 6 inches x 12 inches exposing the wood underneath the pieces of tile. There were also numerous cracked tiles throughout the room with some pieces missing from the corners of the tile. Interview with Resident R16 revealed that the floor has been bad for some time and although he/she has reported it, no one has addressed it. Resident R16 also reported concerns with the sink in his/her bathroom stating it was loose and although he/she does not lean on or use the sink for support, if someone did he/she was fearful it would fall off the wall. Observation of room [ROOM NUMBER]'s bathroom did reveal a sink that was coming away from the wall, was loose and could be moved up and down when any pressure was applied. Observation of room [ROOM NUMBER] on 7/6/26, at 12:22 p.m. revealed the sink in the bathroom was coming away from the wall, was loose and could be moved up and down when any pressure was applied. Interview with Resident R44 revealed he/she was unsure how long the sink had been that way, but he/she did not lean on or use the sink for support. During an interview on 7/8/26, at 11:34 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that room [ROOM NUMBER] had broken and missing tile on the floor and that the sink in bathrooms for both room [ROOM NUMBER] and 210 was coming away from the wall, was loose, and could be moved up and down when any pressure was applied. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain an effective pest control program to ensure a pest free environment in one of two pantries (CD Unit). Findings include: A facility policy entitled Pest Control dated 4/21/2025, indicated Routine pest control procedures will be in place. Observation of the pantry on CD Unit on 7/22/25, at 2:27 p.m. revealed numerous small flying insects on the walls, around the sink, around the garbage can and around the base of the floor where a portion of the baseboard was coming off. During an interview on 7/22/25, at 2:33 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the presence of small flying insects in the CD pantry. LPN Employee E1 stated they are always bad in here and if someone leaves any food on the counters, it is much worse. The facility was unable to provide any evidence of prior pest control treatment to CD pantry. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety, and failed to label food brought into the facility with the resident's name and use by date, and failed to maintain sanitary conditions in one of two pantry refrigerators (CD Unit). Findings include: A facility policy entitled Bare Hand Contact with Food and Use of Plastic Gloves dated 4/21/2025, indicated Single-use gloves will be worn when handling food directly with hands to assure that bacteria is not transferred from the food handlers' hands to the food product being served. The policy further stated that anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Examples include after handling boxes, crates, or packages; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and any time a contaminated surface is touched. A facility policy entitled Food Availability dated 4/21/2025, indicated cleaning and sanitizing refrigerators on a regular cleaning schedule, and as needed. A facility policy entitled Food Brought in from Outside Sources and Personal Food Storage dated 4/21/2025, indicated food and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the resident's name and date and stored in the refrigerator / freezer apart from facility food. A facility policy entitled Food Safety for Your Loved One dated 4/21/2025, indicated food in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. Observation on 7/22/25, at 11:43 a.m. during tray line, revealed that Dietary Employee E2 left the kitchen area with gloved hands, went into the store room closet in hallway, grabbed a large can of chicken noodle soup, came back into the kitchen and opened the can of soup utilizing a can opener, poured the soup into a pan on the stove top, went to the sink, turned on the water and filled the soup can, poured the water into the pan of soup on the stove top, and then threw away the can. Immediately after this at 11:46 a.m. Dietary Employee E2 was observed grabbing a hamburger bun with his/her gloved hand, placing the bun on a plate, using utensils he/she put a hamburger on the bun, grabbed a slice of cheese with his/her gloved hand and placed it on the burger. Immediately after this at 11:47 a.m. Dietary Employee E2 grabbed another hamburger bun with his/her gloved hand, placed the bun on a plate, using utensils he/she put a hamburger in a bowl, used his/her gloved hands to break up the burger, put the burger on the bun, grabbed a slice of cheese with his/her gloved hand and placed it on the burger. Dietary Employee E2 then proceeded to grab three premade grilled cheese sandwiches from a tray with his/her gloved hands and placed them in a skillet. At 11:49 a.m. surveyor stopped Dietary Employee E2 and reviewed the above observations with him/her. Dietary Employee E2 confirmed he/she did the aforementioned and stated he/she tries to remember to change his/her gloves and wash his/her hands but did not do it this time. During an interview on 7/22/25, at 11:50 a.m. Dietary Manager was informed of the above observations and confirmed that Dietary Employee E2 should have changed his/her gloves and washed his/her hands after handling the soup can. Observation on 7/22/25, at 2:27 p.m. on CD unit pantry freezer revealed a 20-ounce bottle of Diet Pepsi with no name and no date. Observation on 7/22/25, at 2:28 p.m. on CD unit pantry refrigerator revealed a 12-ounce can of C4 performance energy drink and a plastic bowl with lid containing applesauce with no name and no date. A dried thick yellow substance was observed on the bottom and 2nd shelf of the refrigerator. During an interview on 7/22/25, at 2:33 p.m. Licensed Practical Nurse Employee E1 confirmed resident freezer / refrigerator in CD unit pantry was dirty and contained items that were not labeled as required. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(e)(2.1) Management

Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days one of five residents reviewed (Resident R5).A facility policy entitled Behavior Health Program dated 4/21/25, indicated that the physician will limit the timeframe for PRN psychotropic mediations to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or prescribing practitioner. Residents R5's clinical record revealed an admission date of 1/13/24, with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs, called mania, and lows, known as depression) liver failure, difficulty eating, gall stones, and heart disease. The clinical record revealed a new physician's order dated 6/22/25, to administer Lorazepam (antianxiety medication) every six hours as needed for 45 days. Further review of Resident R5's clinical record lacked evidence of a physician's rationale for ordering the psychotropic medication past the 14-day limit. Resident R5's clinical record contained a plan of care for ordered anti-anxiety medications and included Ativan (Lorazepam) PRN for 14 days and that it was reordered on 6/22/25, for 45 days. During an interview on 7/24/25, at 2:40 p.m. the Nursing Home Administrator confirmed that there was no evidence of a physician's rationale for ordering the PRN Lorazepam for 45 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store food and food containers in a safe and sanitary manner in two of two nourishment refrigerators (A/B Unit, C/D/Unit). Findings include: A facility policy entitled, Food Safety for your Loved One dated 8/07/24, indicated food or beverages should be labeled and dated to monitor for food safety: food and beverages that have passed the manufacturer's expiration date will be discarded; food or beverage items without an manufacturer's expiration date should be dated upon arrival in the facility and thrown away seven days after the date marked; and foods in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. A facility policy entitled, Food Brought in from Outside Sources and Personal Food Storage dated 8/07/24, indicated that foods and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the resident's name and date. A facility policy entitled, Food Availability dated 8/07/24, indicated that food and nutrition services staff are responsible for cleaning and sanitizing refrigerators on a regular cleaning schedule and as needed. Observation on 8/23/24, at 10:40 a.m. of the pantry refrigerator on the A/B Unit revealed the following food items without a resident name or date: a clear plastic container half full and labeled as ham salad; a white plastic bowl covered with aluminum foil and half full of a rice and corn mixture; a red [NAME] bag that contained a clear plastic wrapping of deli meat and cheese, and a clear plastic container of fresh cut vegetables with a best if used by date of 8/16/24. Observation on 8/23/24, at 10:53 a.m. of the pantry refrigerator on the C/D Unit revealed: a white foam container with chicken tenders and a pint size Chinese take-out container with someone's first name on it and dated 8/07/24. Also in the refrigerator were the following items that lacked a name and date: three pizza boxes that contained various slices of pizza, a black plastic container with a clear lid that contained a piece of meat, one submarine sandwich and a croissant in a cooler bag, black lunch pail that contained two cans of Mountain Dew and a sandwich, and a 3/4 full clear plastic drink cup of dark colored pop with a straw. The shelves and bottom of the refrigerator had dried spills of a variety of colored liquids, food crumbs and debris. During an interview on 8/23/24, during the above observations the Dietary Manager confirmed that the refrigerators on both units contained outdated, unlabeled, and undated food items and the refrigerator of C/D Unit contained the dried spills, food crumbs, and debris. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.18(b)(1) Management

Based on review of facility dialysis (a blood purifying treatment given when your kidneys are not functioning) center contract, facility policy, and clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication for one of one residents reviewed for dialysis (Resident R79). Findings include: Review of dialysis contract between the facility and the dialysis clinic dated 7/18/14, revealed that the responsibility of the skilled nursing facility included that the healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis. If it is determined that a patient is sufficiently stable, this assessment will be communicated to the facility's nurse manager or his or her designee. This assessment and communication will occur prior to each and every transfer of a patient to the dialysis clinic for hemodialysis on an outpatient basis regardless of the number of times any particular patient may be transferred and dialyzed. The agreement further stated that the dialysis clinic shall provide to the facility information which may be utilized in the development and maintenance of the patients care plan and information about how care should be rendered to a patient in emergency and non-emergency situations. Review of facility policy dated 8/7/24, entitled Dialysis indicated It is the policy of this facility to maintain medical record documentation for residents receiving renal dialysis in accordance with state and federal regulations and regulatory guidelines. The policy further stated The renal dialysis provider will provide the facility with copies of reports of all tests performed on the resident during renal dialysis, written physician orders or recommendations for change in medications/treatment and a copy of reports of any unusual events occurring while at the dialysis unit. The reports will be returned with the resident following each treatment. And Should the renal dialysis unit fail to comply with this agreement, the Charge Nurse will notify the facility Administrator who will in turn contact the Administrative Officer in charge of the renal dialysis unit. Resident R79's clinical record revealed an admitted [DATE], with diagnoses that included end stage renal disease (a disease where the kidneys no longer work to meet the body's needs), diabetes, and anxiety. Review of R79's physician orders dated 5/9/24, revealed Resident R79 received dialysis every Monday, Wednesday, and Friday with a chair time of 6:30 a.m. On 8/22/24, at approximately 3:35 p.m. it was requested for evidence that communication between the facility and the dialysis center was occurring with each dialysis treatment every Monday, Wednesday, and Friday for Resident R79. Upon review of dialysis communication documents dated between 5/31/24, and 7/15/24, it was identified that there was no evidence that any evidence of communication was provided by the facility to the dialysis center since 7/15/24, for a total of 16 visits to the dialysis center from 7/15/24, to 8/22/24. During an interview on 8/23/24, at 10:42 a.m. the Executive Director confirmed the lack of communication from the facility to the dialysis center for Resident R79 since 7/15/24, and additionally confirmed that communication is to occur between the facility and the dialysis center for each treatment rendered and the facility should have evidence of this in the resident's clinical record. 28 Pa. Code 211.5(f)(iv)(viii) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R66). Findings include: Review of facility policy dated 8/7/24, entitled Oxygen Concentrators indicated The facility will include cleaning of humidifiers and filters to maintain optimal function and infection control procedures and for filters clean weekly and as needed, rinse thoroughly with clear water, and towel day to remove excess water. Resident R66's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), dementia (loss of cognitive functioning affecting a persons memory and behaviors), and high blood pressure. Resident R66's physician's order dated 2/27/24, revealed that oxygen was ordered at three liters per minute every shift via nasal cannula (tubing that enters into the nostrils to administer oxygen). Further review of physician orders revealed that the oxygen filter is to be cleaned weekly every night shift every Sunday. Observation on 8/20/24, at approximately 12:13 p.m. and on 8/21/24, at approximately 8:52 a.m. revealed that Resident R66's oxygen concentrator had one filter on the back of the concentrator that contained a gray dusty substance. During an interview on 8/21/24, at approximately 8:55 a.m. Licensed Practical Nurse Employee E1 confirmed that the oxygen concentrator filter contained a gray dusty substance and should not. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 21 residents reviewed (Residents R15 and R32). Findings include: MDS instructions for section N0350A Medications - Insulin Injections revealed to Record the number of days that insulin injections were received during the last 7 days or since admission / entry or reentry if less than 7 days. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included Type II diabetes (condition that affects how your body uses insulin), breast cancer, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R15's clinical record revealed a physician's order dated 4/12/24, for Liraglutide injection (an antihyperglycemic [medication to reduce elevated blood sugar levels] injection used to help control blood sugar, which is not classified as an insulin) 1.8 milligrams (mg) one time a day. Further review of Resident R15's clinical record revealed a physician's order dated 4/26/24, for Trulicity injection (an antihyperglycemic injection used to help control blood sugar, which is not classified as an insulin) 1.5 mg every Friday. Resident R15's admission MDS with an Assessment Reference Date (ARD-time period to look back to review resident status) of 4/18/24, indicated Resident R15 received insulin six of the last seven days. Resident R15's quarterly MDS with an ARD of 5/30/24, indicated that Resident R15 received insulin one of the last seven days. Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included morbid obesity, heart failure and hyperglycemia (elevated blood sugar level). Resident R32's clinical record revealed a physician's order dated 5/30/24, for Trulicity injection 1.5 mg every Thursday. Resident R32's quarterly MDS with an ARD of 7/16/24, indicated that Resident R32 received insulin one of the last seven days During an interview on 8/22/24, at 2:09 p.m. the Registered Nurse Assessment Coordinator confirmed that neither Liraglutide or Trulicity are classified as insulin and Resident R15's and R32's MDS's for section N0350A were coded incorrectly and should have been coded as zero. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed provide an environment that enhances resident's quality of life for three of 21 residents reviewed (Residents R25, R65, R69). Findings include: Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia, tremors, need for assistance with personal care, and cognitive communication deficit (communication difficulty that is caused by a cognitive deficit rather than a language or speech deficit). The clinical record lacked evidence of a physician's order and/or plan of care to address him/her consuming meals while sitting in the hall at the nurse's station. Resident R25's most recent Admission/5-Day Minimum Data Set (MDS-standardized assessment tool used to evaluate the health and functional abilities of residents in Medicare or Medicaid certified nursing homes) Section C0500 with an Assessment Reference Date (ARD-a time period to look back for review of resident status) of 6/19/24, indicated that Resident R25's Brief Interview of Mental Status (BIMS-cognitive screening tool used in nursing homes and other long-term care facilities to assess the cognitive condition of residents) score of four (severely impaired cognition). Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included dementia, anxiety, mood disorder, and difficulty eating. The clinical record lacked evidence of a physician's order and/or plan of care to address him/her consuming meals while sitting in the hall at the nurse's station. Resident R65's most recent Significant Change MDS Section C0500 with an ARD of 8/15/24, indicated that his/her BIMS score was a score of one (severely impaired cognition). Resident R69's clinical record revealed an admitted [DATE], with diagnoses that included psychotic disorder, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to perform even the simplest tasks), anxiety, and cognitive communication deficit. The clinical record lacked evidence of a physician's order and/or plan of care to address him/her consuming meals while sitting in the hall at the nurse's station. Resident R69's most recent Quarterly MDS Section C0500 with an ARD of 7/03/24, indicated that his/her BIMS score was a score of three (severely impaired). Observations on 8/22/24, at 12:49 p.m. revealed Residents R65 and R69 feeding themselves lunch at a tray table while sitting in the hall across from the Unit C/D nurse's station, and Resident R25 being fed by staff at a tray table while sitting in the hall across from the Unit C/D nurse's station. During an interview at that time, Registered Nurse Employee E2 confirmed the main dining area is at max capacity so residents eat here, those who cannot eat in their rooms have to eat up here, the resident lounge is not open during meals due to the choking incident. During an interview on 8/23/24, at 10:10 a.m. the Executive Director and Nursing Home Administrator confirmed that there is not enough room for all residents to eat in the main dining area at one time. 28 Pa. Code 205.9(c) Corridors 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10 (a) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of facility policy, clinical records, facility documents, staff documentation, and coroner's report and staff interviews, it was determined the facility failed to provide emergency life-saving interventions as required for one resident who was choking and still breathing where professional licensed staff did not attempt life-saving interventions to Resident R1 as required. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Foreign Body Airway Obstruction Management, last reviewed [DATE], revealed, Facility personnel will be trained on the procedure for Foreign-Body Airway Obstruction [Heimlich Maneuver]. The Heimlich Maneuver is used on conscious adults and thrusts are to continue even if the resident loses consciousness in an attempt to dislodge an obstruction. Review of facility documents entitled, Job Description-Registered Nurse Supervisor revealed that Registered Nurse (RN) Supervisors are expected to assist with or institute emergency measures for sudden adverse developments in residents. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included alcoholic myopathy (disease of muscle tissue), muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). Review of physician's orders revealed that Resident R1's diet was regular textures with meats cut into bite size pieces, allowed thin liquids with direct supervision and meal trays, nectar thick liquids at bedside. Resident R1 was followed by Speech Therapy from [DATE]-[DATE]. Therapy notes indicated that due to documented physical impairments and associated functional deficits, without skilled therapeutic interventions Resident R1 was at risk for: aspiration (food or liquid entering the airway) and that Resident R1 required supervision/assistance at mealtime due to swallowing safety 50 percent to 75 percent of the time. Review of Resident R1's care plan revealed that he/she was to be monitored and staff to document and report to the physician for signs and symptoms of dysphagia, pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan also indicated Resident R1 appears concerned during meals. Review of Resident R1's POLST [Pennsylvania Orders for Life-Sustaining Treatment] dated [DATE], revealed FIRST follow these orders, THEN contact physician, Certified Registered Nurse Practitioner [CRNP] or Physician Assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the physician and Resident R1 and Section A revealed that if the person has no pulse and is not breathing DNR [Do Not Attempt Resuscitation] Allow Natural Death. Section B revealed Medical Interventions person has pulse and/or is breathing as Limited Additional Interventions. Section B was signed by both the physician and Resident R1 revealed the resident wanted oral suction and manual treatment of airway obstruction. Review of information submitted by the facility dated [DATE], revealed, Registered Nurse Supervisor [Employee E1] response STAT [immediately/without delay] to D wing lounge and noted that Resident R1 was nonresponsive, lips cyanotic, resident taking gasps. Review of progress notes revealed documentation completed by RN Employee E1 on [DATE] at 12:12 p.m., which stated, writer called to d lounge. [Resident R1] nonresponsive, lips cyanotic, resident taking gasp. No spo2 [blood oxygen level] obtainable . in house and paged to room. Resident seen one hour prior by CRNP [Certified Registered Nurse Practitioner]. CRNP at her side. No chest movement. No pulse. POLST verified several times. CRNP states CTB [ceased to breath] at 11:40 a.m. Brother .notified. Brother coming to see resident. Review of facility investigation documentation revealed the following written staff interviews: Review of Certified Nursing Assistant [CNA] Employee E2's written statement revealed on [DATE], I was feeding another resident. He/She was starting to spit out food after a few bites. I took him/her up by the nurse's station and then I had to talk to the Therapy lady up at the nurse's station. I didn't come back in like usual to feed a couple other residents in there. Review of CNA Employee E3's written statement revealed, on [DATE], at 11:30 a.m. I helped pass a few trays in D-Lounge. When I left the D-Lounge [CNA Employee E7] was still passing trays. I left to toilet a resident on another hall who had been asking to go at the time trays arrived. Trying to self-transfer. After toileting resident, I was at the desk when I heard [CNA Employee E7] yell for LPN [Licensed Practical Nurse Employee E4] in D-Lounge. That is when I heard [Resident R1] choking. His/her code status was looked up and RN [Employee E1] was called. I did not go down to the lounge at this time, I moved residents in the hall to make a path for anybody who needed to get there quickly. Review of LPN Employee E4's written statement on [DATE], revealed, called to the lounge by other LPN [Employee E5]. This nurse went into lounge LPN [Employee E5] and CNA [Employee E7] were in the lounge. They stated they weren't sure what was going on with [Resident R1]. His/her color was dusky. His/her eyes were big. I asked [Resident R1] if he/she was choking, [Resident R1] looked at me and then went unresponsive. I ran to look at POLST and told LPN [Employee E5] to call RN [Employee E1]. POLST said DNR. I ran and got RN [Employee E1], and we ran back to the lounge. Review of LPN Employee E5's written statement on [DATE], revealed, I was walking down D hall to pass 11 a.m. meds. I stopped in the lounge to ask an aide [Employee E7] a question. When I walked in the resident looked like he/she was going to cough, but she didn't make any noise. Then the resident looked like she was choking. [CNA Employee E7] patted her on the back a couple of times. Resident started looking blue. I ran and grabbed my pulse ox. Resident coughed quietly. [CNA Employee E7] did Heimlich. Resident just turned more blue. I yelled for the resident's nurse, [LPN Employee E4] came. I called [RN Supervisor Employee E1] on the phone to come now. [He/she] came pretty quick. We checked resident was a DNR. She was blue but was still taking a quick breath now and then. The nurse practioner came. We got her in a chair and took her to her room. They called her time of death. The lunch tray cart was in the lounge while they were eating. Review of Occupational Therapist Employee E6's written statement on [DATE] at 11:40 a.m., revealed, called C/D lounge by RN [Employee E1] walking down to C/D lounge- entered C/D lounge resident sitting in dining room armed chair with drool noted on lips, lips lightly blue, and cool to touch, arms resting relaxed at sides, eyes barely open. No active movement observed occasional gasp (whole body) therapist supported resident in upright position-CNA [Employee E7] was behind resident having stated completed Heimlich and upon walking to dining room audibly heard back thrusts being performed, RN [Employee E1], LPN [Employee E5], CNA [Employee E7], LPN [Employee E4] transferred resident out of armed chair into broda wheelchair. Assist from CNA staff Tray without Rije cups. Hot dog pieces all gone but one and bun intact. OT only drink consumed. Subsequent interview conducted with RN Employee E1 on [DATE], at approximately 9:15 a.m., revealed that he/she gave a statement that was sent to the Department of Health; he/she stated it was a bad day and he/she was monitoring in the dining room at the time of the incident. He/She got called to D-wing Lounge and went there after gathering the CRNP, upon arrival the resident took like two gasps of air and then stopped breathing, he/she was a DNR so did not initiate CPR (cardiopulmonary resuscitation). Subsequent interview with LPN Employee E4 on [DATE], at 12:35 p.m., revealed, that he/she had no training on emergency response such as a STAT call over the intercom. He/she was in the facility at time of incident and heard another LPN Employee E5 yelling. He/she went to the lounge and saw Resident R1 going unresponsive, he/she was unsure if the resident was choking at that time and then looked down at Resident R1's meal and noticed a hot dog in front of Resident R1 and that it was not a normal hotdog it was a jumbo hotdog. He/She then smacked Resident R1 on the back and did a finger sweep which he/she did not find anything. He/she stated that Resident R1 is known for eating too fast and attempting to eat too much food at once, so Resident R1 had to be monitored for safety. He/She stated that Nursing Assistant Employee E7 was the only staff member in the D-Wing Lounge at that time and did not see anyone performing the Heimlich on Resident R1. He/She stated that there was no crash cart/suctioning brought to the lounge and that Resident R1 was a DNR with a limited POLST. Subsequent interview with LPN Employee E5 on [DATE], at 12:56 p.m., revealed that he/she had no training on emergency response such as a CPR or STAT code. LPN Employee E5 stated that when he/she entered the lounge the resident looked funny, and his/her body was flopping; Resident R1 was blue in color. LPN Employee E5 stated they ran to get the pulse ox and called the RN Employee E1 on the portable phone while in the lounge. LPN Employee E5 stated that CNA Employee E7 was performing the Heimlich 3 or 4 times and Resident R1 was slow breathing; Resident R1 was slow breathing when RN Employee E1 entered the room, described the breaths as slow with longer than normal gaps in-between, but confirmed that Resident R1 was still moving air. He/she did not see anyone else perform the Heimlich on Resident R1; the crash cart/suctioning was not brought to the lounge. Interview conducted on [DATE], at 11:00 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed, they both responded to the D-Wing Lounge after hearing the alert over the intercom. They stated they entered at the same time as the RN Employee E1 and CRNP Employee E8 and it happened in seconds. Advised there was not any time to call 911 and as they entered, Resident R1 took a couple of more breaths and then he/she was gone. They were unable to provide a statement regarding a timeline and advised the crash cart/suctioning was not taken to the lounge. The DON confirmed they have not conducted any type of competencies or mock drills regarding STAT situations with staff since he/she has been employed there, which has been over 1 year. Statement received via e-mail from CRNP Employee E8 on [DATE], at 1:42 p.m. revealed, The patient was seen early morning [DATE] in stable condition. I was called to the small lounge on the D Hall due to the patient being unresponsive. Upon arrival to the lounge the patient was slumped over in a chair. She had no pulse or respirations. It was communicated to me that she is a DNR. Nursing staff reported they were not aware of the patient eating any food from her lunch tray. She was taken back to her room and the coroner was notified. The facility investigation lacked a written statement for CNA Employee E7 who was the staff member that was in the D-Wing Lounge at the time Resident R1 started to choke and attempted the Heimlich, while yelling for assistance from additional staff. Review of the Resident R1's autopsy report completed by the coroner dated [DATE], revealed there was 3.5 x 2.5 x 2 centimeters [cm--2.54 centimeters equal to one inch] piece of hotdog lodged and blocking the larynx/trachea and numerous large pieces of hotdog in the stomach. Review of Resident R1's death certificate identified the main cause of death as asphyxiation (being deprived of oxygen which can result in suffocation and death) related to choking on a bolus (ball like mixture of food and saliva) of food. The facility's Licensed Professional Staff failed to provide emergency life-saving interventions which would have included but are not limited to, continuing the Heimlich Maneuver and/or utilizing suction for one resident who was choking and still breathing. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy (IJ) situation. The NHA was notified of the IJ situation on [DATE], at 4:39 p.m. and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the DON on [DATE], and approved at 6:31 p.m. The plan included: 1. Facility already implemented process improvement plan through QAPI committee on [DATE]. 2. Facility completed training with staff on responding to emergency choking situations, completed on [DATE]. 3. Facility is working with Healthcare Coalition and Superior Ambulance in getting onsite CPR certification class scheduled, began calls to schedule on [DATE]. 4. Facility implemented that all licensed staff obtain CPR certification online until and in-person onsite class is confirmed. Certifications are obtained and housed in employees personnel file, implemented on [DATE]. 5. Facility has eliminated the use of Lounge Dining and have all residents dining in the main dining room where suctioning is available and additional staff are present effective [DATE]. 6. Audits are being completed five days per week for four weeks, then three days per week f or four weeks, then weekly for four weeks. All audits will be taken to QAPI. On [DATE], between 10:45 a.m. and 3:15 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on [DATE], 2:45 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, facility documents and coroner's report, and staff interviews it was determined the facility failed to provide food in a form designed to meet individual needs for one resident (Resident R1) who choked and ceased to breath as a result. This failure placed nine residents that had similar diet needs for bite-sized pieces at a high risk for death and resulted in an Immediate Jeopardy situation for Residents R2, R3, R4, R5, R6, R7, R8, R9, and R10. Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included alcoholic myopathy, muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). Review of physician's orders revealed that Resident R1's diet was regular texture with meats cut into bite-size pieces, allowed thin liquids with direct supervision and meal trays, and nectar thick liquids at bedside. Review of Resident R1's clinical record revealed he/she was followed by Speech Therapy from 9/12/23-10/11/23 Therapy notes indicated due to documented physical impairments and associated functional deficits, without skilled therapeutic interventions that Resident R1 was at risk for aspiration (food or liquid entering the airway) and that Resident R1 required supervision/assistance at mealtime due to swallowing safety 50 percent to 75 percent of the time. Review of Resident R1's care plan revealed that he/she was to be monitored and staff to document and report to the physician for signs and symptoms of dysphagia, pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan also indicated that Resident R1 appears concerned during meals. Review of Resident R1's meal ticket revealed he/she was to have thin liquids in a regular cup with a Rije cup (a drinking aid for people with swallowing disorders) on the side and a spouted cup for nectar thick liquids (slightly more body than thin liquids used for people with swallowing disorders). An alert on the meal ticket revealed that Resident R1 was to have cut meats. Review of facility bite sized diet guidelines revealed, Soft & Bite-Sized This diet restriction is intended for those that have some chewing ability to break food into smaller pieces and move food around in order to swallow safely. Food served on this diet must be soft and tender, with particle sizes no larger than 1.5 centimeters x 1.5 centimeters (0.59 inches). Review of facility hotdog order revealed that two cases of Smithfield Beef [NAME], five count per pound, frozen, 10-pound package was delivered on 10/10/23. The Smithfield Beef [NAME] served on 10/11/23, were 91 grams per hotdog, when compared to a Ball Park Beef Hot Dog, original length which are 53 grams per hotdog. This information identified that the hotdogs served at the facility on 10/11/23 were almost double the size of a regular hotdog. During an interview on 10/31/23, at 1:55 p.m. Dietary Staff Employee E9 stated, the hotdog was cut, but not in bite-size pieces, the hotdog was in a bun and cut into four equal pieces and there was only one piece of the hotdog left on [Resident R1's] tray and that [Resident R1] did not eat any of the bun. He/she confirmed that the hotdogs were larger than a normal hotdog that you would buy at the grocery store. Subsequent interview with Dietary Staff Employee E9 on 11/1/23, at approximately 1:30 p.m. revealed that he/she provided a description of a bite-sized diet from the facility's diet manual and that a bite-size diet food should be cut into 0.59-inch sized pieces. He/she also said they do not follow this diet that is in the manual because it is not in their electronic system, but it is a good reference to use when a resident is ordered a bite-size diet. Review of physician's orders for Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, revealed all had diet orders comparable to Resident R1 with orders in place for bite-sized meat. Review of the facility policy entitled, Therapeutic Diets Provided To Residents in Long-Term Care last reviewed 8/3/23, revealed, To assure provision of the appropriate diet for each resident and to maximize resident care . Review of information submitted by the facility dated 10/11/23, revealed, .Coroner notified writer that cause of death was accidental, asphyxiation (lack of oxygen and impaired respiration, suffocation), removal of piece of hot dog from resident's airway. Resident's diet was as follows: Regular textures with meats cut into bite-size pieces, sugar substitute, allowed thin liquids with direct supervision and meal trays, nectar thick liquids at bedside. Review of facility investigation documentation revealed the following written staff interviews: Review of Occupational Therapist Employee E6's written statement on 10/11/23, at 11:40 a.m., revealed, called C/D lounge by RN [Registered Nurse Employee E1] walking down to C/D lounge- entered C/D lounge resident sitting in dining room armed chair with drool noted on lips, lips lightly blue, and cool to touch, arms resting relaxed at sides, eyes barely open. No active movement observed occasional gasp (whole body) therapist supported resident in upright position-CNA [Certified Nurse Aide Employee E7] was behind resident having stated completed Heimlich and upon walking to dining room audibly heard back thrusts being performed, RN [Employee E1], LPN [Licensed Practical Nurse] Employee E5, CNA [Employee E7], LPN [Employee E4] transferred resident out of armed chair into broda [type of positioning chair] wheelchair. Assist from CNA staff Tray without Rije cup. Hot dog pieces all gone but one and bun intact. OT only drink consumed. The facility investigation lacked a written statement for CNA Employee E7 who was the staff member that was in the D-Wing Lounge at the time Resident R1 started to choke. Interview with LPN Employee E4 on 10/31/23 at 12:35 p.m., revealed that he/she had no training on emergency response such as a STAT call over the intercom. He/she was in the facility at time of incident and heard another LPN Employee E5 yelling. He/she went to the lounge and saw Resident R1 going unresponsive, he/she was unsure if the resident was choking at that time and then looked down at Resident R1's meal and noticed a hotdog in front of Resident R1 and that it was not a normal hot dog it was a jumbo hotdog. He/She then smacked Resident R1 on the back and did a finger sweep which he/she did not find anything. He/she stated that Resident R1 is known for eating too fast and attempting to eat too much food at once, so Resident R1 had to be monitored for safety. He/She identified that Nursing Assistant Employee E7 was the only staff member in the D-Wing Lounge at that time and did not see anyone performing the Heimlich on Resident R1. He/She stated that there was no crash cart/suctioning brought to the lounge and that Resident R1 was a DNR with a limited POLST. Review of the Resident R1's autopsy report completed by the coroner dated 10/11/23, revealed there was 3.5 x 2.5 x 2 centimeters [cm--2.54 centimeters equal to one inch] piece of hotdog lodged and blocking the larynx/trachea and numerous large pieces of hotdog in the stomach. Review of Resident R1's death certificate identified the main cause of death as asphyxiation (being deprived of oxygen which can result in suffocation or death) related to choking on a bolus (ball like mixture of food and saliva) of food. The facility failed to provide food in a form designed to meet individual needs for one resident (Resident R1) who choked and ceased to breath as a result. This failure placed eight residents that had similar diet needs related to bite-sized pieces at a high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents R2, R3, R4, R5, R6, R7, R8, and R9. The Nursing Home Administrator (NHA) was notified of the IJ situation on October 31, 2023, at 4:39 p.m. and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the Director of Nursing on October 31, 2023, and approved at 6:31 p.m. The approved plan included: 1. Facility already implemented plan through our QAPI committee on October 19, 2023. 2. Facility has reviewed all resident diets to ensure proper diets are provided, completed on October 12, 2023. This review was completed by Dietician, Speech Therapist, Director of Rehabilitation, Certified Dietary Manager, Nursing Home Administrator, and Director of Nursing. 3. Diets have been altered for safety reasons based on residents' needs, orders have been updated as of October 16, 2023. 4. Staff have been educated ensuring food is served in accordance with ordered diet. This education occurred on October 25, 2023. 5. Hot Dogs, and other tubular meats, were removed from the facility menus on October 12, 2023. 6. Audits are being completed five days per week for four weeks, then three days per week for four weeks, then weekly for four weeks. All audits will be taken to QAPI. On November 1, 2023, between 10:45 a.m. and 3:15 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on November 1, 2023, 2:45 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of job descriptions, facility cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) records, facility assessment, and staff interviews, it was determined that the facility failed to ensure that licensed nursing staff have the specific competencies and skill sets necessary to care for resident's needs. Findings include: Review of facility Job Description entitled Licensed Practical Nurse dated ,d+[DATE], revealed that CPR and AED (Automated External Defibrillator-medical device used to help those experiencing sudden cardiac arrest) certification are minimum requirements to perform the job. The review also revealed an essential job function is to attend in-services and/or educational programs in accordance with company and regulatory requirements. Review of Job Description entitled Certified Nursing Assistant dated ,d+[DATE], revealed an essential job function is to attend in-services and/or educational programs in accordance with company and regulatory requirements. Review of Job Description entitled Registered Nurse dated ,d+[DATE], revealed that CPR and AED certification are minimum requirements to perform the job. The review also revealed the Registered Nurse ensures that standards of nursing care are upheld, and policies and procedures are followed. Review of the Facility assessment dated ,d+[DATE], revealed the column Frequency relative to benchmark on the assessment identified that a category for swallowing difficulty and residents with mechanically altered diets was very high which indicated an increase need of competent staff for basic life support including, Heimlich Maneuver (emergency life-saving procedure that is done immediately when a person is choking which can increase the chances of survival after choking) and CPR. Review of facility personnel CPR records revealed 85 out of 135 staff lacked evidence of completing basic life support including the Heimlich Maneuver and/or CPR with the component of hands-on practice and in-person skills assessment. Therefore, the facility's CPR records lacked evidence that 85 of 135 facility staff were evaluated and assessed to be competent in basic life support including the Heimlich Maneuver and CPR. Interview with Nursing Assistant (NA) Employee E10 on [DATE], at 10:30 a.m. revealed that he/she completed CPR online training that consisted of watching videos and reading material then answering 10 questions. There was no hands-on practice or in-person skills completed. The interview also revealed he/she was not trained in basic life support including the Heimlich Maneuver. Interview with NA Employee E11 on [DATE], at 10:50 a.m. revealed that he/she was not trained in Basic Life Support including the Heimlich Maneuver and/or CPR certified. Interview with NA Employee E12 on [DATE], at 10:35 a.m. revealed that he/she was not trained in Basic Life Support including the Heimlich Maneuver and or CPR certified. Interview with Licensed Practical Nurse (LPN) Employee E4 on [DATE], at 12:45 p.m. revealed that he/she was not provided with training on emergency response including basic life support, Heimlich Maneuver and CPR, and what to do once an emergency is identified to prevent a condition from worsening. Interview with LPN Employee E5 on [DATE], at 12:47 p.m. revealed that he/she was not provided with training on emergency response including basic life support, Heimlich Maneuver and CPR, and what to do once an emergency is identified to prevent a condition from worsening. During an interview on [DATE], at 11:00 a.m. the Director of Nursing (DON) confirmed they have not conducted any type of competencies or mock drills regarding STAT (a term used in the medical field for response to an emergency) situations with staff since he/she has been employed there, which has been over one year. The DON also confirmed that competencies should be completed for staff. During an interview on [DATE], at 11:15 a.m. the Nursing Home Administrator confirmed there was no evidence that 85 facility personnel completed hands-on practice and in-person skills assessment with the CPR certifications. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that professional licensed staff implemented life-saving interventions in response to a choking episode that led to death and failed to ensure the provision of food in a form to meet individual resident needs. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to lead and direct the overall operations of the nursing home facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business operations. The NHA's essential job functions include being responsible to ensure quality and proper resident care and services and possess and display a practical knowledge of nursing facility operations. Review of the job description for the DON revealed that the DON's purpose is to manage the overall operations of the Nursing Department in accordance with company policies, standard nursing practices, and regulatory guidelines. The DON's essential job functions include being responsible to monitor and analyze clinical reports including falls, weights, wounds, dietary consultants, pharmacy consultants, etc. and take appropriate actions, assume administrative authority, responsibility and accountability for all functions, activities, and training of the Nursing department, and ensure nursing staff is educated and prepared to perform duties at an acceptable level. Based on the findings that the facility failed to ensure that professional licensed staff implemented life-saving interventions in response to a choking episode that led to death and failed to ensure the provision of food in a form to meet individual resident needs for all residents, the NHA and the DON failed to fulfill their purpose and essential job duties to ensure that the Federal and State guidelines and regulations were followed. Refer to F836 and F805 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policies, facility documentation and staff interviews, it was determined that the facility failed to ensure facility staff were properly trained to provide basic life support including, Heimlich Maneuver (emergency life-saving procedure that is done immediately when a person is choking which can increase the chances of survival after choking) and cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) for 85 of 135 facility personnel. Findings include: Review of facility policy entitled Cardiopulmonary Resuscitation dated [DATE], revealed facility personnel will be trained on the imitation of cardiopulmonary resuscitation and basic life support. Review of facility policy entitled Foreign Body Airway Obstruction Management dated [DATE], revealed facility personnel will be trained on the procedure for foreign body airway obstruction. Review of the facility personnel CPR certification records as of [DATE], revealed 85 out of 135 staff personnel lacked evidence of completing basic life support including the Heimlich Maneuver and or CPR with the component of hands-on practice and in-person skills assessment. Further review of facility personnel CPR certification records revealed 34 CPR certifications were through National CPR Foundation. Review of National CPR Foundation training program revealed that the program does not include completion of hands-on practice and in-person skills assessments. The National CPR Foundation program indicated Learn useful-life skill techniques through video demonstration. Review of facility personnel CPR certification records revealed one certification through the National Health and Safety Association. Review of the National Health and Safety Association program revealed that the program does not include completion of hands-on practice and in-person skills assessment. The National Health and Safety Association program indicated No manikin required. Review of facility personnel CPR certification records revealed one certification through the American Health Care Academy. Review of the certification revealed an internet based activity and does not indicate completion of hands-on practice and in-person skills assessment. Review of facility personnel CPR certification records revealed one certification through CPR Select. Review of CPR Select program revealed that the program does not include completion of hands-on practice and in-person skills assessment. CPR Select program indicated No Skills test required. Interview with Nursing Assistant (NA) Employee E9 on [DATE], at 10:30 a.m. revealed that on [DATE], he/she was told by facility management to go online and get CPR certified. Interview also revealed that the CPR online training that he/she completed consisted of watching videos and reading material then answering 10 questions. There was no hands-on practice or in-person skills completed. Review of NA Employee E9's CPR certificate revealed it was from the National CPR Foundation. Interview with NA Employee E10 on [DATE], at 10:50 a.m. revealed that on [DATE], he/she was told by facility management to go online and complete CPR training. Interview also revealed that he/she did not complete the training course online. During an interview on [DATE], at 11:15 a.m. the Nursing Home Administrator confirmed there was no evidence that 85 facility personnel completed hands-on practice and in-person skills assessment with the CPR certifications. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined the facility failed to properly store foods/maintain proper sanitation in the main kitchen. Findings include: Review of facility policy entitled, Cleaning Dishes/Dish Machine last reviewed 8/03/23, revealed that Low Temperature Dishwasher using chemicals to sanitize that the wash temperature should be 120 degrees Farenheit and that the final rinse sanitization should be at 50 parts per million (50 PPM). It further indicated that staff should check to ensure that the soap and sanitizer are dispensing properly and thermal strips should be used. Review of facility policy entitled, Cleaning Instructions: Freezers last reviewed 8/03/23, revealed that freezers will be defrosted as needed (when the frost is greater than or equal to 1/4 inch thick, the freezer should be defrosted). Review of the EcoLab Operation Manual dated 10/29/07, for the ES Series Chemical Sanitizing Dishmachine, indicated for daily machine preparation to check levels in all chemical containers and replace if empty. Observations on 9/11/23, at approximately 2:00 p.m. and again on 9/12/23, at 10:00 a.m. revealed the dishmachine was being used without any chemical sanitization. Observations on 9/12/23, at 8:55 a.m. of the freezers in the basement area, there was an excessive accumulation of ice on the top shelf and door of Freezer 1, that filled the shelf and only a corner of a product on that shelf was slightly observable. Freezer 3 had an accumulation of ice on the top shelf and a deep freezer also had an accumulation of ice inside. During the above observations and review of information, the Dietary Manager confirmed that the dishmachine was operating without the chemical sanitizer and the freezers should not have excessive accumulation of ice. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services

Based on review of facility grievances and resident council minutes, observations and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and delay of meal service to residents. Findings include: Review of the tray line delivery times dated 1/18/22, revealed A Wing residents (the last unit delivered) were scheduled to receive their lunch at 12:00 p.m. Review of the June Resident Council Minutes indicated concerns voiced regarding meal times. Review of the July and August grievance logs revealed 14 complaints regarding dietary concerns and that staff were educated. Eleven resident interviews (Residents R14, R27, R44, R48, R56, R57, R58, R64, R75, and R83) all indicated that all meals are not delivered timely. The interviews indicated that residents have been receiving breakfast as late as 10:00 a.m., lunch as late as 2:00 p.m. and dinner as late as 8:00 p.m They all indicated that this has been an ongoing issue since June. Observations on 9/12/23 and 9/13/23, at 1:00 p.m. or one hour late, revealed that the meal trays destined for A Wing left the kitchen. During an interview on 9/11/23, at 11:00 a.m Cook Employee E9 confirmed that there were only two staff for the morning shift and that there was only one cook due to call offs. During an interview on 9/14/23, at 11:15 a.m. the Nursing Home Administrator confirmed that the cook called off the morning of 9/13/23, delaying the meal delivery times. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policies, facility documents, and clinical records, observations, and staff interview, it was determined that the facility failed to ensure proper documentation regarding treatment and services for one resident receiving wound care (Resident R1), and administration of medications for 16 residents on the C Hall Unit (secured unit). Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included Cerebral Palsy, high blood pressure, diabetes, schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and anxiety and was a female. Review of Resident R1's clinical record revealed skin/wound notes by a Certified Registered Nurse Practioner (CRNP) on the following dates: 9/12/23, 9/09/23, 8/29/23, 8/22/23, 8/15/23, 8/08/23, 8/01/23, 7/25/23 and 7/18/23, all indicating that the patient is a [AGE] year old male. During an interview on 9/13/23, at 2:15 p.m. the Nursing Home Administrator confirmed that the skin/wound notes were documented in error regarding Resident R1 being a female. Review of a facility policy entitled Administration Procedures for All Medications dated 8/03/23, indicated that after administration staff are to document the administration in the Medication Administration Record (MAR). Review of September 2023 MARs for residents on the C Hall Unit revealed a lack of documentation that physician prescribed evening medications were administered on 9/09/23. Review of a facility document entitled Medication Administration Audit report provided on 9/13/23, indicated that the 16 residents on C Hall Unit did not receive physician prescribed medications on the evening shift of 9/09/23. During an interview on 9/13/23, at 9:00 a.m. the Director of Nursing confirmed that there was no documentation to support that physician prescribed medications were administered to 16 residents on C Hall Unit on 9/09/23. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.5(f)(x) Medical records

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for the potential unauthorized access of medications on one of four medication carts (B Cart), failed to discard expired multi-dose vial Lantus insulin (long-acting insulin used to maintain healthy blood sugar levels) and label an opened Lispro insulin (fast-acting insulins used to control high blood sugar) pen with a resident's name and date opened on one of four medication carts (A Cart), and failed to label a multi-dose container of Tuberculin solution (used to test for the disease tuberculosis) with the date it was opened in one of two medication storage rooms (C/D Unit). Findings include: Review of a facility policy entitled, Storage of Medications dated 8/03/23, indicated that medication carts are locked when they are not attended, all expired medications will be removed from the active supply, and when the original seal is initially broken the container or vial will be dated and the expiration date of the container or vial will be 30 days from the opening. Observation on 9/11/23, between 11:55 a.m. and 11:58 a.m. revealed the B Cart in the B Unit hallway was unsecured and unattended. During an interview on 9/11/23, at 11:58 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the B Cart was parked in the B unit hallway and was unsecured and unattended and that medication carts should be locked when not in view. Observation on 9/11/23, at 3:45 p.m. revealed that A Cart contained an opened multi-dose vial of Lantus dated as opened on 8/07/23, and an unsealed Lispro insulin pen that lacked a label containing a resident's name and an open date. During an interview at that time LPN Employee E2 confirmed that the multidose vial of Lantus was expired and should have been discarded on 9/07/23, and that there was no way to tell which resident was to receive the Lispro insulin or what date it was opened. Observation on 9/12/23, at 9:03 a.m. of medication storage room on the C/D Unit revealed an opened multi-dose vial of Tuberculin solution that lacked a date it was opened. During an interview at that time Registered Nurse Employee E3 confirmed that the opened multi-dose vial of Tuberculin should contain a label indicating the date it was opened. During an interview on 9/14/23, at 8:45 a.m. the Director of Nursing confirmed that the unlabeled, undated Lispro, undated Tuberculin multi-dose vial, and the expired Lantus should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documents, observations, and staff interviews it was determined that the facility failed to provide housekeeping services necessary to maintain a clean, homelike environment for one of 22 residents (Resident R71). Findings include: Review of a facility document provided on 9/13/23, entitled C-Hall Scrub Rooms indicated that Resident R71's room (room [ROOM NUMBER]) was assigned to be cleaned on Tuesdays, and indicated that the staff are to: clean the tops, sides, and front of nightstands, pull out bed and nightstands from walls, and sweep and mop the floors. Resident R71's clinical record revealed an admitted [DATE], with diagnoses that included sudden and long-term respiratory (breathing) failure, chronic obstructive pulmonary disease, (COPD- a group of diseases that cause airflow blockage and breathing-related problems), and cognitive communication deficit (inhibits or prevents one from performing normal mental processes such as talking, remembering things, problem-solving and safety awareness). Observations on 9/11/23, at 12:44 p.m. and on 9/12/23, at 9:40 a.m. of Resident R71's room revealed two white powder bottles and a nebulizer mask (mask that covers the mouth and nose usually held onto the face with an elastic band and used to treat respiratory disorders) on the floor between the bed and the nightstand. Observation on 9/13/23, at 11:38 a.m. of Resident R71's room revealed one white powder bottle and a nebulizer mask on the floor between the bed and the nightstand. During an interview on 9/13/23, at 11:44 a.m. the Director of Nursing confirmed the presence of the white powder bottle and nebulizer mask on the floor between the bed and nightstand. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e) (2.1) Management

Based on observations, review of facility policy and documents, and staff and resident interviews it was determined that the facility failed to maintain a temperature range between 71 to 81 degrees Fahrenheit in 49 of 51 occupied resident rooms, resulting in immediate jeopardy to the residents. Findings include: Review of the facility Emergency Disaster Plan manual revealed it lacked a policy/procedure for the facility to follow in the instance of air conditioning failure. During an interview on 6/01/22, at 3:55 p.m. the Assistant Director of Nursing and the Infection Control/Education Registered Nurse confirmed that the Emergency Disaster Plan manual lacked a policy/procedure for the facility to follow in the instance of air conditioning failure. Review of a facility temperature log indicated the following ambient (air) temperatures in degrees Fahrenheit: 5/31/22, at 6:00 p.m. 81.4, 5/31/22, at 10:00 p.m. 82.4, 6/01/22, at 2:00 a.m. 84, 6/01/22, at 6:00 a.m. 82.4, and 6/01/22, at 10:00 a.m. 83.4. Observations on 6/01/22, between 12:10 p.m. and 2:14 p.m. of occupied resident rooms revealed the following ambient temperature measurements in degrees Fahrenheit: - 77.7 Room 318 (Resident's family installed a personal window air conditioning unit.) - 80.2 Room 410 (Resident had two personal fans operating and the curtains drawn.) - 82.4 Room 107 - 82.5 Room 104, and 111 - 82.7 Room 102, 103, and 109 - 82.9 Room 110, and 212 - 83.1 Rooms 101, 105, 106, 108, 204, 206, 207, 208, 209, 210, 211, 313, and 409 - 83.3 Rooms 202, 203, 317, 404, 405, 406, 407, 411, 412, and 413 - 83.4 Rooms 402, 403, and 408 - 84 Rooms 301, 302, 303, 304, 312, 314, 315, and 316 - 84.2 Rooms 305, 306, 307, 308, 309, 310, and 311 Observation of the ambient temperature at the nurse's stations on A/B Wing and C/D Wing was 83.3 degrees Fahrenheit. Interviews on 6/01/22, between 12:10 p.m. and 2:14 p.m. revealed Residents R1-R18 confirmed they were uncomfortably hot. At the time of the interviews, Resident R2 was observed with a wet towel draped over his/her head, Resident R14 had stated that he/she had just splashed himself/herself with cool water from the sink, and Resident R10 had a wet cloth around his/her neck. During an interview on 6/01/22, at 12:30 p.m. Resident R9's representative confirmed that the facility temperature has been unbearably hot since his/her recent admission. Review on 6/01/22, at 1:28 p.m. of an air conditioning repair work order from a Heating, Ventilation, and Air Conditioning (HVAC) Company Employee E7 dated 5/19/22, revealed that the air conditioning units were not working and needed replaced due to age and deterioration, and during an interview at that time the Director of Maintenance confirmed there was no evidence the facility received an estimate from the plumbing and heating company and/or attempted to obtain further estimates and/or schedule the replacement of the faulty air conditioning units. Review of an estimate from the HVAC Company Employee E7 for replacement of the air conditioning units dated 5/24/22, and received by the facility on 6/01/22, at 2:37 p.m. via email and upon request revealed, an estimated cost of replacing the air conditioning units. At 3:50 p.m. the Registered Nurse Supervisor and the previous Director of Maintenance reported that the boilers to the heating system were still engaged and that was not permitting the air conditioning to turn on. An Immediate Jeopardy (IJ) situation was identified to the Assistant Director of Nursing and the Infection Control/Education Registered Nurse on 6/01/22, at 3:55 p.m. (Nursing Home Administrator and Director of Nursing unavailable) related to the elevated ambient temperatures and resident reports of being uncomfortably hot. The NHA was made aware (via phone conference) that Immediate Jeopardy existed for the facility's failure to ensure that a safe and comfortable temperature was maintained, and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility. Observations on 6/01/22, at approximately 4:30 p.m. revealed that nursing staff was obtaining resident room temperatures and the surveyor confirmed that the staff was recording the surface temperature reading and not the ambient temperature. Temperature gun instruction manual reviewed and confirmed with the Director of Maintenance that staff is to be recording the ambient temperature, which is higher than various surface areas (metal, wood, plaster, concrete). During an interview on 6/01/22, at 6:25 p.m. the Nursing Home Administrator confirmed that the facility had not received any additional estimates for replacing the air conditioning units and that the policy/procedure to follow in the instance of air conditioning failure was not accessible to facility staff. On 6/01/22, at 7:15 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. Facility air conditioning was restored at 100% on 6/01/22, at 3:40 p.m. due to a functionality of the boiler still partially being on. Boilers were shut down and cool air was flowing immediately making noticeable difference in facility and resident room temperatures. 2. Re-temps of all resident rooms was initiated at 4:10 p.m. to ensure temps were within normal range of 71-81 degrees. Log provided. Temps will continue to be taken every 4 hours for the next 48 hours and recorded. - Temps will continue to be monitored every 4 hours and recorded for two weeks, then weekly and then monthly for 2 months. - Cooling rooms had already been established throughout the building prior to 6/01/22, for on exceptionally warm days. Main dining room, Activities Room, and C/D Dining room. - Audits will be completed daily for two weeks, and weekly for 2 months of the resident room temperatures and recorded. - All audits will be reviewed as part of the monthly QAPI process. - Facility emergency preparedness policies are in place and copy will be provided to surveyor onsite. Facility staff will be re-educated by Maintenance Director or designee on emergency preparedness as it relates to environment of the building during hot weather and high heat days. - A quote had been obtained from on HVAC Company Employee E7 (was out to facility on 5/20/22 and quote sent to facility on 5/24/22), for mini split units of the CD unit of facility. - In addition, two other vendors were contacted to provide quotes and were scheduled for onsite visits the week of 5/30/22 by HVAC Company Employees E8 and E9. 3. Systemic measures - The Administrator or designee will conduct education with facility staff on facility emergency preparedness during periods of excessive heat due to air conditioning or electrical failure. - Once quoted have all been obtained, facility will make a determination for air conditioning unit throughout the facility to be maintenance/repaired and/or replaced ad recommended by HVAC professional bids. - Should any further systemic issue or functionality issue be identified with the facility air conditioning, Administrator or designee will notify the department of health field office immediately. After review of facility temperature logs, observations of all resident room ambient temperatures, eight resident interviews and five staff interviews, the implementation of the above stated action plan was confirmed on 6/02/22, at 2:40 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management