Every finding on record at Transitions Healthcare North Huntingdon

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms (A/B Nursing Unit Medication Room). Findings include: Review the facility policy Storage of Medications dated 4/1/26, indicated that outdated, contaminated, or deteriorated items will be removed from stock and disposed of accordingly. During an observation of the A/B nursing unit medication room on 4/28/26, at approximately 12:32 p.m. the following was observed:(5) Medline foley catheter 20 french with an expiration date of 9/28/25.(10) Medline foley catheter 22 french with an expiration date of 12/28/25.(5) Amsino foley catheter 20 french with an expiration date of 9/3/25.(6) BD MaxPlus needleless connector with an expiration date of 8/17/25.(1) Osang Health Care covid-19 antigen self test with an expiration date of 12/12/23.(1) BBL CultureSwab collection and transport system with an expiration date of 10/10/25.(6) BBL CultureSwab collection and transport system with an expiration date of 12/27/25.(4) McKeeson IV catheter 26-gauge needles with an expiration date of 10/20/25.(2) Medline Suresite IV auto safety IV catheter 22-gaugle needles with an expiration date of 2/28/26.(2) Covideien monoject 25-gauge needles with an expiration date of 1/31/26.(1) Medline Suresite IV auto safety IV catheter 20-gaugle needles with an expiration date of 2/28/26.(1) Medline safety syringe 25-gauge needle with an expiration date of 3/4/26.(6) Wolf-pak IV start kit with CHG prevanties pad with an expiration date of 11/30/25.(8) Caresite extension set with caresite luer access device 8-inch with an expiration date of 2/28/26.(1) Medline sterile 0.09% normal saline 100 mL with an expiration date of 3/1/26.(1) [NAME] medical drainage bag 600 mL with an expiration date of 1/5/26.(1) Amsino Amsure foley insertion tray with an expiration date of 10/31/26. During an interview on 4/28/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services

Based on review of policies and clinical records, as well as observations, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications to three of 32 residents reviewed (Resident R26, R31, and R119).Findings include: The facility policy Administration Procedure for All Medications reviewed on 4/1/26, previously reviewed on 4/1/25, indicated medications will be administered in a safe and effective manner. In Section IV step three states to clean hands using antimicrobial soap and water or facility approved hand sanitizer before a med pass, before handling medications and before contact with a resident. In step four it states to use a barrier (e.g. clean disposable tray or plastic cup) to carry medication containers into the resident's room and to separate the supplies and the over the bed table or other surface on which the supplies are placed, when medications are administered. The facility policy Handwashing/Hand Hygiene reviewed on 4/1/26, previously reviewed 4/1/25, indicated effective hand hygiene reduces the incidence of healthcare associated infections. In the section of Procedure step seven states to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: (c) Before preparing or handling medications. During an observation during medication administration on April 28, 2026, at approximately 8:30 a.m. revealed Licensed Practical Nurse (LPN) Employee E2 prepared to administer medications to Resident R26 and obtained Lopressor from medication blister pack (30-day supply in individual blister bubbles). The nurse touched the medication to place it on the pill splitter to give half the dose of the medication, proceeded to cut the pill in half and then dropped the medication on top of the medication cart, picked it up with her bare hands and placed it into the cup of medications. She then administered the medication to Resident R26. During an interview with LPN Employee E2 on April 28, 2026, at 8:32 a.m. confirmed that she should not have touched the medications and should have obtained a new tablet after the medication dropped onto the cart. During an observation during medication administration on April 28, 2026, at approximately 8:45 a.m. revealed LPN Employee E4 prepared to administer medications to Resident R31 and obtained Claritin, Senna/Docusate, Folic Acid, B12 from stock medications (medications used for multiple residents). The nurse touched the tablets with bare hands and placed the tablets into the cup for medications. LPN Employee E4 obtained Lyrica, Norco, Amiodarone, Bumetanide, Eliquis, Fluoxetine, Vistaril, Potassium Chloride, Spironolactone and Symproic, via blister pack by popping the pills directly into his hands before putting them into the medication cup. Once all medications were dispensed, he picked the medications up by his bare hands again and placed them in a small pouch (used to crush medications) and proceeded to crush the medications and then emptied the crushed medications into chocolate pudding to administer to the resident. During an observation during medication administration on April 28, 2026, at approximately 8:55 a.m. LPN Employee E4 touched the tablets with his bare hands and placed the medications into the cup to be administered. LPN Employee E4 prepared to administer medication to Resident R119 and obtained Iron from the stock medications and then proceeded to pop from blister packs Amlodopine, Wellbutrin, Duloxetine, Metformin, Eliquis and Famotidine into his hand and placed them in the medication cup to be administered. During an interview with LPN Employee E4 on April 28, 2026, at 9:00 a.m. confirmed that he should not pop or pour the medications into his hands and if he does, he should wear gloves. During an interview with the Director of Nursing on April 28, 2026, at 1:30 p.m. confirmed staff were not to touch resident's medications with their bare hands. 28. Pa. Code 201.14(a) Responsibility of licensee.28. Pa. Code 211.10(d) Resident Care policies.28. Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of five residents reviewed (Residents R56).Findings include: Review of the facility policy Hemodialysis, Home Hemodialysis dated 4/1/26 with a prior review date of 4/1/25. The policy indicates Each resident is provided with a dialysis communication binder, so the facility and dialysis center can communicate. Daily dialysis treatments sheets are utilized for each treatment session. Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/3/26, indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R56's physician order dated 3/18/25, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Chair time scheduled for 10:30 a.m. Review of Resident R56's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center]. Resident R56's dialysis communication forms from 3/27/26 through 4/27/26 revealed incomplete communication on the following dates: Dialysis Center nurse did not complete vital signs or weight pre or post treatment and dialysis nurse did not sign the dialysis communication forms:3/27/26, 3/30/26, 4/3/26, 4/6/26, 4/8/26, 4/10/26, 4/22/26, 4/24/26 Dialysis Center nurse did not complete vital signs or weight post treatment and dialysis nurse did not sign the dialysis communication forms:4/1/16 Dialysis Center nurse did not sign the dialysis communication forms:4/15/26, 4/17/26, 4/20/26, 4/27/26 During an interview on 4/29/26, at 10:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of eight sampled residents (Residents R53, and R133).Findings include: Review of the facility policy Oxygen Concentrators reviewed on 4/1/26, with a prior review date of 4/1/25. The policy indicates The facility will include cleaning of humidifiers and filters to maintain optimal function and infection procedures. Procedure change cannula weekly (11-7) and as needed. Filters (11-7) clean weekly and as needed. Review of the facility policy CPAP/BIPAP reviewed on 4/1/26 with a prior review date of 4/1/25. Verify physician's order and oxygen source if ordered. Connect one end of the oxygen tubing to the oxygen enrichment adapter and the other end to the oxygen source. Cleaning the system weekly. Review of Resident R53's admission record indicated he was admitted on [DATE]. Review of Resident R53's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/2/26, indicated the diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), heart failure (the heart is unable to pump enough blood to meet the body's need for blood and oxygen), and hypertension (high blood pressure). Review of Resident R53's current physician orders dated 4/10/26, indicated resident BiPAP (machine that makes you inhale and exhale more easily) setting to bleed in 2 liters per minute of oxygen. Resident is on 5 liters per minute of oxygen. Change oxygen tubing and set-up weekly every night shift, every Sunday label tubing with date when changed and as needed. Review of Resident R53 clinical record on 4/27/26 revealed, resident did not have orders for oxygen concentrator maintenance related to filters, humidifier bottle, tubing on (orders were placed on 4/29/26 after facility notification). Interview and observations on 4/27/26, at approximately 10:30 with Registered Nurse (RN) Employee E1, Resident R53, was observed, with oxygen tubing connected to their oxygen concentrator that had a label and date of 4/6/26. Review of Resident R133's admission record indicated he was originally admitted on [DATE]. Review of Resident R133's MDS dated [DATE], indicated the diagnoses of respiratory failure (lungs cannot provide enough oxygen or remove enough carbon dioxide), chronic obstructive pulmonary disease (COPD progressive lung disease limiting airflow to the lungs), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear, and uneasiness). Review of Resident R133's current physician orders dated 4/19/26, indicated resident is on 2 liters per minute of oxygen. Oxygen equipment, change tubing/nasal cannula/mask/humidifier bottle and clean filter weekly (when in use). Review of Resident R133 vital sign documentation dated 4/17/26 indicates resident was on oxygen at 2 liters per minute via nasal cannula. Interview and observations on 4/27/26, at approximately 10:40 a.m., with Licensed Practical Nurse (LPN) Employee E2, Resident R133, was observed, with oxygen tubing connected to their oxygen concentrator, the tubing had not been labeled or dated. Resident stated the tubing had not been changed. During an interview on 4/27/26, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for three of eight residents (Resident R12, R23, R99).Findings include: Review of the facility policy Care Plan-Comprehensive dated 4/1/26, previously dated 4/1/25, indicated each resident will have a comprehensive care plan developed that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. Review of Resident R12's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R12's clinical record Minimum Data Set (MDS-a periodic assessment of resident's needs) dated 2/2/26, indicated diagnoses of stroke (blood flow to the brain is blocked or a vessel bursts causing rapid brain cell death), high blood pressure, cirrhosis(liver scarring resulting in long term damage, often leading to liver failure), diabetes(high blood sugar due to insufficient insulin production), Post-Traumatic Stress Disorder (PTSD- a mental health condition triggered by experiencing or witnessing terrifying events, causing long-lasting flashbacks, nightmares, severe anxiety, and avoidance of behaviors). Review of Resident R12's care plan, dated 4/10/26, indicated resident has altered mood, behaviors related to depression, history. of PTSD, anxiety, verbal behaviors, inappropriate comments towards women, and racial slurs. Resident is to be assessed and monitored for trigger of mood/behaviors, triggers loss of independence and feelings of helplessness. Review of Resident R12's Physician orders dated 7/28/21, consult and follow-up as needed with psychology service. Review of Resident R23's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R23's clinical record MDS dated [DATE], indicated diagnoses of traumatic brain dysfunction (disruption in normal brain function, caused by an external force-resulting in physical, cognitive, and emotional dysfunction), aphasia (language disorder caused by brain damage-difficult to speak, write and understanding language), seizure disorder (neurological condition with recurring, unprovoked surges of abnormal electrical activity in the brain). Review of Resident R23's Physician orders dated 2/27/26, indicated enteral feeding every four hours and check tube, check placement every shift, cleanse the area around stoma every shift, change syringe and tubing every day, elevate the head of bed during feedings and when giving medications, administer Isosource 1.5 feeding three times a day, 250ml bolus feed. Review of Resident R23's care plan, dated 4/9/26, indicated no plan of care for a gastrostomy tube (g-tube that is inserted through the abdomen into the stomach for feeding) or tube feedings. Review of Resident R99's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R99's MDS dated [DATE], indicated diagnoses of high blood pressure, neurogenic bladder (nerve damage from disease or injury interrupts signals between nervous system and bladder leading to incontinence, urinary retention or frequent infections), spina bifida (neural tube defect where the spine and spinal cord do not for properly in the womb, can lead to physical disabilities, leg weakness, bowel/bladder issues and hydrocephalus (fluid on the brain)). Review of Resident R99's Physician orders dated 3/28/26, indicated to flush foley catheter with 30ml of sterile water as needed for blockage and provide foley care every shift. On 4/17/26, order for Indwelling Foley catheter size 18 French with 10ml balloon, connected to drain bag. Review of Resident R99's care plan, dated 4/28/26, indicated no plan of care for indwelling foley catheter. During an interview on 4/29/26, at approximately 10:00 a.m. with Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON reviewed Resident R12, R23 and R99's care plans. The DON and NHA asked for clarification for R12's triggers and it was explained that there was no documentation to state what triggers caused his PTSD to be exacerbated, it was just documented to watch behaviors thus being deficient in plan of care. The DON then reviewed Resident R23's care plan and stated it should have been updated to reflect current physician orders for tube feedings and care and also reviewed Resident R99's care plan and stated it should have been updated to reflect current physician orders to reflect an indwelling catheter placement and care. The facility failed to make certain that residents had an updated, person-centered care plan individualized to each specific resident's needs for three of eight residents (Resident R12, R23, R99). 28 Pa. Code 201.24 (e)(1)(5) Admissions Policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, facility records, resident and staff interviews, it was determined that the facility failed to make certain call lights were accessible and answered timely for six of thirteen residents as required (Resident R1, R2, R3, R4, R5, and R6).Findings include: The facility policy Call Bells dated 4/1/25, indicated the purpose of this procedure is to respond to the resident's requests and needs when using the call bell system for assistance. If answering the call light from the nurse's station, please ensure that staff respond to resident request immediately. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident R1's clinical record indicated admission to the facility on 6/8/25. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/26, indicated diagnoses of adjustment disorder mental health condition intense of emotional and behavioral symptoms), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 12. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:00 a.m. Resident R1 stated she uses the call light when she needs help. It takes a half hour or more to get help it can take more than an hour. What can you do, just keep pushing the button and eventually someone will come. Review of Resident R2's clinical record indicated admission to the facility on 7/22/24. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/6/26, indicated diagnoses of hypertensive chronic kidney disease (kidney damage from long term high blood pressure), adjustment disorder mental health condition intense of emotional and behavioral symptoms), and hypertension (high blood pressure) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R2 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers, unable due to medical condition. During an interview and observation on 3/11/26, at approximately 11:10 a.m. Resident R2 stated she uses the call light when she needs help. It takes a half hour and sometimes a lot longer than that to get help when you use your light. Review of Resident R3's clinical record indicated admission to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of osteomyelitis of vertebra (infection in the bones of the spine), bipolar disorder (significant mood swings hypomanic and depressive), and hypertension (high blood pressure) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R3 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers requires partial/moderate assistance, (helper does less than half the effort). During an interview and observation on 3/11/26, at approximately 11:20 a.m. Resident R3 stated she uses the call light when she needs help. It takes thirty minutes at a minimum, the other day I waited from 11:45 a.m. to 1:15 p.m. Review of Resident R4's clinical record indicated admission to the facility on 5/4/21. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD disease that blocks airflow to the lungs), diabetes mellitus (body cannot properly use or make insulin), and depression, a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R4 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance). During an interview and observation on 3/11/26, at approximately 11:30 a.m. Resident R4 stated she uses the call light when she needs help. Resident R4 stated you always have to wait sometimes only thirty minutes other times it is much longer. Review of Resident R5's clinical record indicated admission to the facility on 4/3/25 and discharged [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R5 is dependent with toilet hygiene (helper does all the effort) and GG0170 toilet transfers, dependent (helper does all the effort). During a review of resident grievances, Resident R5 filed a grievance on 12/31/25 documenting his experiences and hours waiting for his brief to be changed after calling for assistance. Review of Resident R6's clinical record indicated admission to the facility on 2/15/26. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/21/26, indicated diagnoses of hypertension (high blood pressure), heart failure (heart is unable to pump enough blood to meet the body's needs for blood and oxygen), and chronic obstructive pulmonary disease (lung disease that blocks airflow making breathing difficult) a BIMS of 11. Review of Section GG: Functional Abilities GG0130, indicated that Resident R6 is substantial/maximal assistance with toileting hygiene, (helper does more than have the effort) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:40 a.m. Resident R6 stated she uses the call light when she needs help. Resident R6 stated you always have to wait when you need help, I have waited so long on occasion I have even called 911 when it takes too long. During a review of the resident council minutes of 1/26/26 and 2/27/26 contained documentation of calls bells are not being answered in a timely fashion. During an interview on 3/11/26 at 2:30 p.m. the Nursing Home Director and the Director of Nursing confirmed the facility failed to make certain call lights were accessible and answered timely. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Based on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of thirteen residents (Resident R1, R5 and R7).Findings include: Review of the Resident Rights policy last reviewed 4/1/25, indicated that the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident R1's clinical record indicated admission to the facility on 6/8/25. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/26, indicated diagnoses of adjustment disorder mental health condition intense of emotional and behavioral symptoms), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 12. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:00 a.m. Resident R1 stated the facility makes her use a bedpan when she needs to move her bowels. I have an order for the staff to get me up to the bedside commode, but they won't do it anymore. One day the bedside commode was taken out of my room and has never returned. I have asked and they just told me to use the bedpan. I would prefer to use the bedside commode. During a review of Resident R1 clinical record did reveal a physician ongoing order dated 7/4/25 for patient to utilize bedside commode, at bedside in room, with an assist x2 for functional transfers. Review of Resident R5's clinical record indicated admission to the facility on 4/3/25 and discharged [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R5 is dependent on toilet hygiene (helper does all the effort) and GG0170 toilet transfers, dependent (helper does all the effort). During a review of grievances, Resident R5 filed a grievance on 12/31/25 documenting his experiences and hours waiting for his brief to be changed after calling for assistance. I called for a nurse multiple times. I spoke to a nurse aide around 4:30 p.m. she said she would be back but didn't come back until after the incident was over and apologized. I texted my daughter at 7:38 p.m. and asked her to call the facility for me. My daughter called and spoke with a staff member who said she would handle it right away. The nurse came in but then it took another 30-40 minutes to find an aide to change me. I went from 9:30 a.m. to 8:30 p.m. without having my brief changed. Review of Resident R7's clinical record indicated admission to the facility on 5/17/25 Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R7 requires substantial/maximal assistance, (helper does more than have the effort) and GG0170 toilet transfers, not attempted, resident was unable to perform this activity prior to admission. During a review of grievances, Resident R7 filed a grievance on 12/23/25 documenting her experience. I was placed on the bedpan at 10:15 p.m. fell asleep and woke up at 11:43 and was still on the bed pan. Resident called for staff and had bedpan removed. During an interview on 3/11/26 at 2:30 p.m. the Nursing Home Director and the Director of Nursing confirmed the facility failed to make certain that care was provided in a manner which maintained resident dignity. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R2 and R3). Findings include: Review of facility policy Administration Procedure for All Medications dated 04/01/25, indicated that medications will be administered in a safe and effective manner. The policy further stated, Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to administration. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/25/25, included diagnoses of COPD and high blood pressure. Review of a physician order dated 3/20/25, indicated to give 12.5 mg (milligrams) of metoprolol (a medication to treat elevated blood pressure) one time per day. The order further stated to hold the medication if the systolic blood pressure was less than 100 (mm Hg). Review of Resident R2's January 2026 Medication Administration Record (MAR) revealed the scheduled medication was administered on the following dates:-1/08/26, blood pressure documented in the MAR as 98/61.-1/09/26, blood pressure documented in the MAR as 98/61.-1/10/26, blood pressure documented in the MAR as 98/63.-1/12/26, blood pressure documented in the MAR as 87/56.-1/13/26, blood pressure documented in the MAR as 97/54. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], included diagnoses of diabetes and high blood pressure. Review of a physician order dated 12/27/25, indicated to give 5 mg of lisinopril (a medication to treat elevated blood pressure) one time per day. The order further stated to hold the medication if the systolic blood pressure was less than 120 (mm Hg). Review of Resident R3's failed to include documentation of a blood pressure measurement since 12/29/25. During an interview on 1/15/25, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify the medical provider of a change in condition for one of four residents (Resident R1).Findings include: Review of the facility policy, Change in Condition dated 4/1/25, indicated it is the policy of the facility to inform residents, medical providers, and the resident representative of a change in the resident's condition. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/30/25, included diagnoses of chronic kidney disease (gradual loss of kidney function) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C: Cognitive Patterns indicated that Resident R1 did not have cognitive impairment. Review of Resident R1's progress notes since admission on [DATE], through 11/16/25, failed to reveal documentation of tremors, convulsions, seizures, or Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) or Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty maintaining balance), or yelling out. Review of the plan of care initiated 7/5/22, indicated that Resident R1 was at risk for complications related to high blood pressure. The goal listed in the care plan was, Resident's blood pressure will range within parameters set by MD. Included in the interventions was, Observe for signs and symptoms of elevated blood pressure (systolic BP >140, diastolic BP >90, dizziness, flush face, headache, nosebleed, nausea/vomiting). Review of a progress note dated 11/17/25, at 1:18 p.m. indicated, it was passed on from 11-7 nurse that resident was having parkinson's like tremors and has no history of. This nurse and cna (nurse aide) adjusted resident numerous times in bed d/t flopping about and rapidly flapping legs with knees bent. resident opens eyes for very short moments. given prn (as needed) pain medication at 11am d/t (due to) yelling out in pain, but not verbal as to where her pain is located. while up in wc (wheelchair), she is arching her back as if she is having a seizure, and snoring very loudly. Resident took 3 bites of sandwich and then immediately started snoring again. RN sup aware and assessed. Review of a skilled nursing note dated 11/17/25, at 2:02 p.m. indicated Resident R1 was yelling out in pain. Sections that indicated medical provider notification resident responsible party notification were documented as na (not applicable). Review of a progress note dated 11/17/25, at 5:07 p.m. indicated that Resident R1 was transported to the hospital for severe back pain. Found with eyes closed, head back hands and arms in posturing position. Legs with spasms and jerking movement. Unable to feed self with rigid hands. Review of a progress note dated 11/17/25, at 7:26 p.m. indicated, Spoke with [hospital nurse] for status update, resident was admitted to ICU (intensive care unit) and intubated (lifesaving medical procedure that uses a tube to keep the airway open to breathe). Per [hospital nurse] 'she tanked when she arrived at ER, resident became unresponsive and BP (blood pressure) and temp dropped significantly, she is septic and had to intubated.' Review of Resident R1's vital sign record indicated that her oxygen level on 11/17/25, was documented at 92% at on room air at 1:15 p.m. and 91% on room air at 3:04 p.m. Further review of the oxygen level records failed to reveal a percentage lower than 95% since her admission date. Review of Resident R1's vital sign record indicated that her temperature of 97.1 ahrenheit was flagged by the electronic charting system as abnormal on 11/17/25, at 1:15 p.m. Further review of the clinical record failed to reveal documentation that the medical provider was notified of a change in condition when it occurred. During an interview on 1/13/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the medical provider of a change in condition for one of four residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four medication carts (orchards unit).Findings include:Review of the facility's Safeguarding of Posted Protected Health Information (PHI) dated 4/1/25, indicated the facility will protect the privacy of resident ' s PHI from intentional or unintentional view when posting information. Posted information may include information located at the bedside, on whiteboards, on walls, or other public areas. During an observation on 11/6/25, at approximately 9:50 a.m. a medication cart in hallway was left unattended with an open laptop displaying resident identifiable information, any passerby could see resident personal and confidential information. During an interview on 11/6/25, at approximately 9:57 a.m. Employee E1 confirmed the observation of a medication cart in hallway was left unattended with an open laptop displaying resident identifiable information, any passerby could see resident personal and confidential information.During an interview Employee E2 at approximately 10:00 a.m. Employee E2 Licensed Practical Nurse, confirmed she had left the medication cart in hallway unattended with an open laptop displaying resident identifiable information. During an interview on 11/6/25, at 1:20 p.m. the Nursing Home Administrator and Director of Nursing confirmed the above observation that the facility failed to maintain the confidentiality of residents' medical information as required.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of facility documents and resident interviews and observations, it was determined that the facility failed to ensure sufficient staffing to meet resident need for nine of thirteen residents (Resident R1. R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: During an interview on 9/3/25, at 10:30 a.m. Resident R1, stated that call light response times can be long. During an interview on 9/3/25, at 10:35 a.m. Resident R2, when asked if she felt the facility had sufficient staff stated, No. Resident R2 further confirmed that call she has waited up to an hour and a half for call light response During an interview on 9/3/25, at 11:29 a.m. Resident R3, when asked if he felt the facility had sufficient staff stated, Not always, sometimes they are a little short-staffed. During an interview on 9/3/25, at 11:35 a.m. Resident R4, when asked if he felt the facility had sufficient staff chuckled, then stated, When they are fully-staffed. During an interview on 9/3/25, at 11:41 a.m. Resident R5, when asked if she felt the facility had sufficient staff stated, No. Resident R5 further confirmed that call light response takes a long time, stating, Do you want a list? Resident R5 then provided the following call light response times, that she had written down on a notepad:8/13/25, call light turned on at 1:13 p.m., answered at 1:43 p.m. 8/21/25, call light turned on at 9:40 a.m., answered at 10:00 a.m 8/21/25, call light turned on at 12:15 p.m., answered at 1:10 p.m. 8/24/25, call light turned on at 7:18 a.m., answered at 7:50 a.m. 8/24/25, call light turned on at 9:25 a.m., answered at 9:50 a.m. 8/30/25, call light turned on at 4:00 p.m., answered at 4:20 p.m. 9/02/25, call light turned on at 10:50 a.m., answered at 11:42 a.m. Resident R5 stated, My aide was at lunch. Oftentimes, nobody else crosses the line to answer lights. They come in to shut the light, and instead of putting me on the bedpan, they say, I'll get your aide. During an interview on 9/3/25, at 11:48 a.m. Resident R6, when asked if she felt the facility had sufficient staff stated, No, it doesn't seem like it. When asked about call light response, Resident R6 stated, Sometimes you put your call light on and you don't get anyone. Resident R6 further stated that she feels rushed when she is bathed, and doesn't feel she is provided enough time to get fully clean. During a group interview on 9/3/25, at 12:05 p.m. with Residents R7, R8, and R9, when asked if she felt the facility had sufficient staff Resident R7 stated, Sometimes not. Resident R9 shook her head negatively. When asked about call light response, Resident R7 stated, I'd be happy with a half hour. Resident R8 stated, Today they were coming in and shutting the light, but not doing anything. Resident R9 stated, Sometimes I wait a long time for help, especially at night. Last night I didn't get to bed until 11 o'clock, because the 3-11 was agency and didn't help me to bed. Observation at this time revealed Resident R9 to have facial hair on her chin. Review of the Resident Council minutes from 6/21/25, indicated that the group voiced a concern about long call light response times. Review of the Resident Council minutes from 8/27/25, indicated that the group voiced a concern about long call light response times. Review of a grievance filed by Resident R3 dated 7/6/25, indicated, I did not get changed on the 11:00 p.m. to 7:00 a.m. I was soaked and so was my bed. During an interview on 9/3/25, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure sufficient staffing to meet resident needs for nine of thirteen residents.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 policies, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R69) A review of the facility policy Administration Procedures For All Medications dated 4/1/25, indicated medications will be administered in a safe and effective manner and after administration document in the MAR (medication administration record) or TAR (treatment administration record) as necessary. A review of the clinical record indicated that Resident R69 was admitted to the facility on [DATE], with diagnoses that included heart disease, dementia, and asthma. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/25, indicated the diagnoses remained current. A review of Resident R69's physician orders dated 1/23/25, indicated to administer oxygen via n/c (nasal cannula) at 4L (liters) per minute continuously every shift. A review of Resident R69's MAR dated May 2025 did not include documentation that the resident received oxygen as ordered on 5/4, 5/9, 5/13, 5/14, 5/15, 5/20, 5/22, 5/23, and 5/27/25. During an interview on 5/28/25 , at 1:45 p.m. the Nursing Home Administrator confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R69. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of clinical record and staff interviews, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of three residents (Resident R43). Finding include: Review of the facility's policy, Change of Condition, with a review date of 4/1/25, and 4/1/24, reported that the facility must notify the resident's representative of the change and any changes made to the resident's plan of care and document in the medical record. Assist with any contacts desired between the family, resident, and Physician/CRNP (Certified Registered Nurse Practitioner) within HIPPA guidelines. Attempt to contact the resident representative at frequent intervals, until notified of the change and interventions, and document all attempts to notify resident representative. Review of Resident R43's Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/22/25, indicated diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness (bleeding between the brain and the tissue covering the brain), dysphagia (difficulty swallowing), diabetes (too high or too low of blood sugar), seizures (abnormal activity in the brain that can cause jerking movements, loss of consciousness, blank stares or other symptoms). Further review of the MDS indicated the resident's Brief Interview for Mental Status assessment (BIMS) was 99 indicating the resident has a severe impairment where they can not complete the interview to obtain a value for mental status. Review of prior physician order dated 4/9/25, indicated Ativan 0.5mg Oral Tablet, Give 1 tablet (0.5mg) once a day for anxiety. Review of the physician orders dated 4/18/25, Ativan 0.5mg Oral Tablet, Give 0.5mg in a.m. Give 0.25 mg at bedtime for anxiety. Review of the physician orders dated 4/18/25, revision 4/28/25, Ativan 0.5mg Oral Tablet, Give 0.25 mg at bedtime for anxiety. Review of the physican orders dated 12/20/24, Haldol 2mg/1ml, Give 0.5 ml Oral Solution twice a day. Review of the physician orders dated 3/13/25, Haldol 2mg/1ml, Give 0.5 ml once a day at bedtime, order was discontinued on 3/20/25. Review of Resident R43's nurse progress notes April 19, 2025-May 2025 and Psychiatry recommendations from April 2025-May 2025 revealed no evidence that the resident's husband or other representative was notified of the new orders, discussed the advantage and disadvantage of medication decrease and alternative options. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 5/30/25 at 11:22 a.m., confirmed that the facility failed to inform resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for Resident R43 as required. 28 Pa Code 201.29(j) Resident Rights. 28 Pa Code 211.10(c) Resident Care policies. 28 Pa Code 211.12(d)(1) Nursing Services.

Based on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to properly design, approve, and follow the Winter five week cycle menu and modifications of the cycle menu. (Winter menu Cycle weeks one, two, three, four and five). Findings include: A review of the facility's Menu Planning policy date 12/31/24, revealed that menu planning will be completed by the facility at least two weeks in advance of service. Regular and therapeutic diets will be written to provide a variety of foods served, adjusted for seasonal changes and in adequate amounts at each meal to satisfy recommended daily allowances. The registered dietitian (RD) will approve all menus. A review of the facility's Sample Menu Shell for Diet Extensions template date 12/31/24, revealed therapeutic diets include: Regular/Regular no added salt packet, Mechanical soft/moist, minced/ground, Mechanical soft bite size, Pureed, Consistent carbohydrate, and Consistent Carbohydrate Pureed. A review of the facility's Portion Control policy date 12/31/24, revealed that residents will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to make certain that accurate portion sizes are served. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so staff can refer to the proper portions for each diet. A review of the facility's Winter five week cycle menu extension sheets implemented October 2024, revealed that the extension sheets failed to provide guidance for regular and therapeutic diets as outlined on the Sample Menu Shell for Diet Extensions template. The extension sheets failed to provide portion sizes for all diets and the combined guidance for Mechanical soft and Puree diets failed to provide guidance on food item consistency which created the potential for dietary staff to serve inaccurate portion sizes and food consistency. The extension sheets were previously approved (date unknown) by former facility RD Employee E4, her last date of employment with the facility was 12/27/24, the facility failed to provided documented evidence that the facility's RD had reviewed and approved the menu extension sheets as required. During an interview on 2/5/25, at 11:15 am the Food Service Director (FSD) Employee E 2 revealed that the dietary department staff utilizes documents maintained in a binder for guidance regarding portion sizes and food consistencies. A review of these documents revealed the following documents: * SLP (Speech Language Pathologist) Mech (Mechanical) Soft Recommendations which outlined recommendations for residents being served the therapeutic diet Mechanical Soft. The recommendations stated no rice, no raw fruits and vegetables, pineapple is not okay even if ground /pulsed, as well as other recommendations. The document contained no documented evidence of the facility's RD review and approval of these recommendations. * Puree Serving Guidelines which provided guidance for portion sizes indicated that portions range from one half cup to a cup for fruits and vegetables, grains, protein and dairy. It was noted that a typical serving size for a puree diet for seniors is generally to be one half cup to three fourths cup per meal of pureed food. The guidance provided conflicting recommendations of portions sizes for puree diets which created the potential for inappropriate inaccurate portions of food products served to residents served a puree diet. The document contained no documented evidence of the facility's RD review and approval of the guidance. * Small, Regular and Large Portion Sizes document contained no documented evidence of the facility's RD review and approval of the guidance. A review of the facility's Mechanical Soft/Puree menu extension sheets revealed on Thursday lunch week one of the cycle menu Mechanical soft diets received Rice pilaf although the SLP's recommendations failed to permit rice to be served to this diet. On Saturday Dinner week three it was indicated to serve pineapple to Mechanical soft and puree diets although this food product is not permitted for these diets. All five weeks of the Mechanical Soft/Puree menu extension sheets failed to provide food consistency guidance for meals served to resident requiring mechanically altered food products such as chopped, minced, and ground meats as well as pureed food products. During an interview on 2/5/25, at 11:25 am [NAME] Employee E3 confirmed that the Mechanical Soft/Puree menu extension sheet for Saturday Dinner week three permitted pineapple to be served to these therapeutic diets. [NAME] Employee E3 stated she would serve the mechanical soft residents crushed pineapple and a pureed fruit (based on availability) to the residents served a puree diet. She confirmed that the SLP guidance states no pineapple is to be served to residents that receive a Mechanical soft diet. During an interview on 2/5/25, at 11:30 am the FSD Employee E2 confirmed that the facility modified the Wednesday Lunch menu for week three and was serving the residents a chef salad. A review of the facility's substitution log revealed that the facility was substituting chef salad for those resident's that receive a renal diet. A review of the facility's week at a glance menu for cycle week three revealed the modification to the Wednesday lunch menu. The substitution log and the week at a glance menu failed to provide evidence that the facility pre planned the menu modification, menu and substitution review and approval by the facility's RD as required. During an interview on 2/5/25, at 11:30 am the FSD Employee E2 confirmed that the facility failed to properly design, review and approve the facility's Winter five week cycle menu as required which created the potential for conflicting guidance which may result in residents being provide inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diet. Pa Code: 211.6(a)(b) Dietary services.

Based on observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms, dining room and hallways) as required. (resident rooms, dining room, and hallways) Finding include: During an observation of the facility on 2/5/25, at 10:30 am the following was revealed: * Resident room [ROOM NUMBER] W (window) the area behind the resident's bed headboard contained peeling and scuffed paint. * Resident room [ROOM NUMBER] W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint * Resident room [ROOM NUMBER] W the area behind the resident's bed headboard contained peeling paint * Resident room [ROOM NUMBER] D (door) and W the area behind the resident's bed headboard contained peeling wall paper. * the doors to the dietary department contained scuff marks and peeling paint * the hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster * a wall in the dining room contained peeling paint. * the door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering. * the wooden handrails throughout the facility contained gashes that contained splintering wood and non smooth unfinished surfaces, some of which where located in the following hallways: outside the dietary department and outside the conference room. During an interview on 2/5/25, at 10:45 am the Nursing Home Administrator and Maintenance Director Employee E1 confirmed that the facility failed to maintain the facility in a homelike environment. Pa Code: 207.2 (a) Administrator's responsibility

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for seven of 20 residents (Resident R9, R13, R17, R26, R36, R64, and R92). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admitted plus 13 calendar days), and an annual MDS assessment was to be completed no later than the Assessment Reference Date (ARD). Resident R9 had an admitted [DATE], with an MDS completion due date of 2/21/24. Resident R13 had an ARD of 3/4/24, with an MDS completion date of 3/21/24. Resident R17 had an admitted [DATE], with an MDS completion due date of 2/21/24. Resident R26 had an admitted [DATE], with an MDS completion due date of 5/6/24. Resident R36 had an ARD of 3/8/24, with an MDS completion date of 3/25/24. Resident R64 had an ARD of 3/7/24, with an MDS completion date of 3/25/24. Resident R92 had an admitted [DATE], with an MDS completion due date of 4/14/24. During an interview on 6/7/24, at 9:52 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the above late MDS assessments, stating that the previous RNAC left without providing notice, and was found to have multiple assessments overdue. During an interview on 6/7/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for seven of 20 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of five residents reviewed (Resident R23, R65, R84, and R87). Findings include: A review of the facility Advanced Directive and Advanced Care Planning reviewed 9/23/23, 1/10/24, and 4/10/24, indicated it is the policy and intent of the facility to inform and provide residents with written information regarding their right to formulate advanced directives for the purpose of prospectively identifying a healthcare decision maker, clarifying treatment preferences, and developing individualized goals of care near end of life. A review of the medical record indicated Resident R23 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R23 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R65 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R65 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses that included pulmonary fibrosis (lungs become scarred and damaged causing difficulty in breathing), reduced mobility, and obesity. A review of the clinical record failed to reveal an advance directive or documentation that Resident R84 was given the opportunity to formulate an Advance Directive. A review of the clinical record indicated Resident R87 was readmitted to the facility on [DATE], with diagnoses that included scoliosis (abnormal curvature of the spine), difficulty speaking, and diabetes. A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advance Directive. During an interview on 6/7/24, at 9:40 a.m. Social Worker Employee E2 confirmed that the clinical record did not include documentation that Resident R23, R65, R84, and R87 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of resident group interview, Ombudsman interview, and observations it was determined that the facility failed to provide a private space for the resident group for ten of ten residents (GR100, GR101, GR102, GR103, GR104, GR105, GR106, GR107, GR108, and GR109). Findings include: During a group interview on 6/5/24, at 1:30 p.m. a Resident Group meeting was conducted in the facility dining room. Signage was posted by the facility on the doors of both sides of the dining room, indicating that a private resident group was being conducted, and not to enter. During the group interview, facility staff entered the group 13 times, to utilize the dining room to proceed from one side of the building to the other. When a facility staff member who entered the dining room was asked by the surveyor if signage was posted asking for staff not to enter the room, she confirmed that it was. When asked why she entered, she stated, To go to the front office. After this interruption, the surveyor facilitating the group interview exited the room, informed the Nursing Home Administrator (NHA) of the continued interruptions, and requested that the group was provided privacy. While continuing to conduct the group interview, a staff member was observed through the window of the dining room door, standing directly on the other side, which allowed her to hear the group discussion. The resident group interview was again paused to allow the surveyor to instruct the staff member that she cannot listen to the group meeting. The staff member confirmed that she was posted there to not allow any further entrance of staff to the meeting. The surveyor then had to request that she step further back, and gestured to an area approximately 10-15 feet from the door, and indicated that she can still prevent interruptions from there, without having to be within inches of the door. When the group was asked if the interruptions usually occurred during their Resident Council groups, Group Resident GR108 responded, Welcome to our world. During an interview with the Ombudsman on 6/6/24, at 12:05 p.m., she confirmed that she has been present in previous resident groups that have been interrupted and further confirmed that the trainings she holds for resident peers had also been interrupted. During an interview on 6/7/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility layout has a connecting hallway, and staff do not need to utilize the dining room to proceed from one side of the building to the other and further confirmed that the facility failed to provide a private space for the resident group for ten of ten residents, 28 Pa. Code 201.18(b)(1) Management.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (Orchards medication room). Findings include: Review of the facility policy Storage of Medications dated [DATE], indicated medications are and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. During an observation on [DATE], at 11:20 a.m. of the Orchards medication room, the following was observed: -(57) vacutainers with an expiration date of [DATE]. -(1) intravenous access (IV) start kit with an expiration date of [DATE]. -(1) IV start kit with an expiration date of [DATE]. -(2) IV start kits with an expiration date of [DATE]. -(13) Povidone-iodine swabsticks with an expiration date of [DATE] -(10) disposable scalpels with an expiration date of [DATE]. -(1) bottle of glucometer testing solutions with an expiration date of [DATE]. -(1) vial of insulin, opened and undated. During an interview on [DATE], at 11:30 a.m. the Director of Nursing confirmed the above items were expired. During an interview on [DATE], at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on observations and staff interview it was determined that the facility failed to maintain call light equipment for five of seven residents (Resident R1, R2, R3, R4, and R5). Findings include: During an observation on 5/19/24, at 2:24 p.m. the lights above the room doors for Resident R1/R2's room, Resident R3's room, Resident R6/R7's room were noted to be illuminated. During an observation on 5/19/24, at 2:25 p.m. revealed the nurses station call light monitoring panel only showed Resident R6/R7's room to be alarming. The lights were still noted to be illuminated over the doors at this time. During an interview on 5/19/24, at 2:25 p.m. Nurse Aide (NA) Employee E1, when asked why the lights were not illuminated on the monitoring panel, stated, That doesn't work. During an interview on 5/19/24, at 2:27 p.m. NA Employee E2, when asked why the lights were not illuminated on the monitor, gestured to the call light monitoring panel stated, It's hit or miss if it works. During an observation on 5/19/24, at 2:33 p.m. the light above the room doors for Resident R4/R5's room was noted to be illuminated. During an observation on 5/19/24, at 2:34 p.m. revealed the nurses station call light monitoring panel did not show any rooms to be alarming. The light was still noted to be illuminated over the door at this time. During an interview on 5/19/24, at 2:40 p.m. the Director of Nursing confirmed that the facility failed to maintain call light equipment for five of seven residents. 28 Pa. Code: 205.67(k) Electric Requirements for Existing Construction.

Based on review of policies, clinical records, investigation reports, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 39 residents reviewed (Resident 47), resulting in harm to the resident, a laceration that required sutures in the emergency room , caused by an inappropriate transfer. Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 1, (YEAR), included that the resident had the right to be free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress). The facility's policy regarding transfers, dated (MONTH) 1, (YEAR), indicated that all resident care was to be provided in a safe, appropriate manner in accordance with the individual resident's care plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated (MONTH) 22, (YEAR), revealed that the resident was severely cognitively impaired, had a history of [REDACTED]. The resident's care plan, dated (MONTH) 2, (YEAR), revealed that she had impaired cognitive function related to dementia (a group of symptoms that affects memory and thinking and interferes with daily life), was at risk for falls, was blind in the left eye, had hearing loss, and had [DIAGNOSES REDACTED]. A nursing note for Resident 47, dated (MONTH) 2, (YEAR), at 3:15 p.m. revealed that the resident was assisted to a chair from her bed by Nurse Aide 10 and suffered a laceration to her left leg. The nurse aide stated that the leg was bumped on the wheelchair during the transfer. The registered nurse assessed the wound, administered first aid, and notified the physician that there was an obvious need for suturing. The resident was transported to the emergency room where the wound was described as a gaping five centimeter (cm) laceration to the left lower leg extending into the subcutaneous tissue (below the layers of skin) and the emergency room report indicated that the laceration was repaired with four sutures and the total wound length was five centimeters. A written statement from Nurse Aide 10, dated (MONTH) 2, (YEAR), revealed that she assisted Resident 47 from her bed to the chair by herself, and she did not know that the resident required the assistance of two for transfers. Education records for Nurse Aide 10 revealed that on (MONTH) 24, (YEAR), she signed that she received orientation and education pertaining to the facility's accident prevention policies, including where to find a resident's transfer status and the importance of the care plan. The facility's completed investigation information revealed that Nurse Aide 10 approached another nurse aide earlier in the shift and questioned the aide regarding the care of both Resident 47 and her roommate, and the two nurse aides checked the transfer status for both residents, which was posted on the inside of each resident's wardrobe closet, and which indicated that Resident 47 required two staff for all transfers. An interview with the Nursing Home Administrator on (MONTH) 29, (YEAR), at 2:30 p.m. confirmed that Nurse Aide 10 failed to follow Resident 47's care-planned intervention to be transferred with the assistance of two staff. The facility reported the event to the Department of Health, the Area Agency on Aging, and the local police on (MONTH) 3, (YEAR). On (MONTH) 3, (YEAR), after the facility completed its investigation, it submitted the investigation findings to the Department of Health. The facility also terminated Nurse Aide 10's employment based on the conclusions of its investigation. The facility re-educated the staff on its transfer and accident prevention policies. Education was initiated on (MONTH) 2, (YEAR), continued on (MONTH) 3 and 7, (YEAR), and was completed on (MONTH) 9, (YEAR), when 100 percent of staff were reeducated. The facility conducted several audits from (MONTH) 5 through (MONTH) 1, (YEAR). The audits showed that the staff was compliant with the facility's policy regarding resident transfers and residents' transfer statuses were followed. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. Previously cited 5/14/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/14/18, 7/27/17, 5/4/17, 12/9/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/14/18, 10/17/17, 7/27/17, 5/4/17, 2/8/17, 12/9/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/6/18, 5/14/18, 12/19/17, 10/2/17, 7/27/17, 3/8/17, 1/6/17, 12/9/16, 7/14/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/14/18, 12/19/17, 10/17/17, 10/2/17, 7/27/17, 7/14/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/6/18, 5/14/18, 12/19/17, 10/17/17, 10/2/17, 7/27/17, 5/4/17, 3/8/17, 2/8/17, 1/6/17, 12/9/16, 7/14/16.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were transferred safely and in accordance with their care plans and physican's orders for one of nine residents reviewed (Resident 2), resulting in a fall with a fractured bone for the resident. Findings include: The facility's policy regarding mechanical lifts, dated (MONTH) 1, (YEAR), indicated that a mechanical lift (a devices that uses hydraulic power to lift and transfer a resident from surface to surface) was to be used when transferring a resident if they required more than moderate assistance or were totally dependent on staff for transfers. Two staff were required for all mechanical lifts, including sit-to-stand lifts (transfer a resident while supported in a standing position). A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated (MONTH) 10, (YEAR), indicated that the resident was confused, did not ambulate (walk), and had range of motion deficits on one side of her body. The resident's care plan and physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 3, (YEAR), indicated that a nurse aide reported that after she put the resident into the wheelchair after using the Hoyer lift, she started to slide out of the wheelchair onto the floor. The nurse found the resident on her buttocks in front of her wheelchair. There was no documented evidence that the resident's care plan and physician's orders [REDACTED]. Interview with the Director of Nursing on (MONTH) 8, (YEAR), at 8:50 p.m. confirmed that on (MONTH) 3, (YEAR), Resident 2 was transferred with the assistance of one staff and a Hoyer lift, and that her care plan and physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 22, (YEAR), revealed that the resident was on the floor on her left side and had facial grimacing with palpation (touching) of her left leg. Investigation information submitted by the facility, dated (MONTH) 22, (YEAR), revealed that a nurse aide attempted to transfer Resident 2 with the use of a Sara lift (a sit-to-stand lift that requires the resident to bear weight) by herself, instead of with a Hoyer lift with two staff members, which resulted in the resident being lowered to the floor. An X-ray report for Resident 2, dated (MONTH) 22, (YEAR), revealed that the resident had a [MEDICAL CONDITION] left femur (lower end of the thigh bone near the knee). A nursing note dated (MONTH) 23, (YEAR), indicated that the resident's left leg was contracted (drawn up) and that she yelled out in pain with any movement in bed. An undated physician consultation report indicated that the resident's distal femur had moderate displacement (abnormal placement/alignment of the bone) and impaction (shortening of the bone caused by the fracture) and that she was not a surgical candidate. Interview with the Director of Nursing on (MONTH) 8, (YEAR), at 8:50 p.m. confirmed that Resident 2 was not transferred with a Hoyer lift and the assistance of two as care planned and ordered by the physician. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 7/27/17, 5/4/17, 12/9/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/27/17, 12/9/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/27/17, 5/4/17, 12/9/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/17/17, 7/27/17, 5/4/17, 2/8/17, 12/9/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/19/17, 10/2/17, 7/27/17, 3/8/17, 1/6/17, 12/9/16, 7/14/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/19/17, 10/17/17, 10/2/17, 7/27/17, 7/14/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/19/17, 10/17/17, 10/2/17, 7/27/17, 5/4/17, 3/8/17, 2/8/17, 1/6/17, 12/9/16, 7/14/16.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of nine residents reviewed (Resident 2), resulting in a fall with a fractured bone for the resident. Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 1, (YEAR), included that the resident had the right to be free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress). The facility's policy regarding mechanical lifts, dated (MONTH) 1, (YEAR), indicated that a mechanical lift (a devices that uses hydraulic power to lift and transfer a resident from surface to surface) was to be used when transferring a resident if they required more than moderate assistance or were totally dependent on staff for transfers. Two staff were required for all mechanical lifts, including sit-to-stand lifts (transfer a resident while supported in a standing position). A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated (MONTH) 10, (YEAR), indicated that the resident was confused, did not ambulate (walk), and had range of motion deficits on one side of her body. The resident's care plan and physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 22, (YEAR), revealed that the resident was on the floor on her left side and had facial grimacing with palpation (touching) of her left leg. Investigation information submitted by the facility, dated (MONTH) 22, (YEAR), revealed that a nurse aide attempted to transfer Resident 2 using a Sara lift (a sit-to-stand lift that requires the resident to bear weight) by himself, instead of with a Hoyer lift with two staff members, which resulted in the resident being lowered to the floor. The facility's investigative report regarding Nurse Aide 3, dated (MONTH) 26, (YEAR), revealed that the nurse aide was in possession of the nurse aide report form (contains information about each resident's care needs, including transfer status) at the time of the transfer, and that the nurse aide acknowledged that he transferred Resident 2 with a Sara lift when she should have been transferred with a Hoyer lift. An X-ray report for Resident 2, dated (MONTH) 22, (YEAR), revealed that the resident had a [MEDICAL CONDITION] left femur (lower end of the thigh bone near the knee). A nursing note dated (MONTH) 23, (YEAR), indicated that the resident's left leg was contracted (drawn up) and that she yelled out in pain with any movement in bed. An undated physician consultation report indicated that the resident's distal femur had moderate displacement (abnormal placement/alignment of the bone) and impaction (shortening of the bone caused by the fracture) and that she was not a surgical candidate. Interview with the Director of Nursing on (MONTH) 8, (YEAR), at 8:50 p.m. confirmed that Resident 2 was not transferred with a Hoyer lift and the assistance of two as care planned and ordered by the physician. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/27/17, 5/4/17, 12/9/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/17/17, 7/27/17, 5/4/17, 2/8/17, 12/9/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/19/17, 10/17/17, 10/2/17, 7/27/17, 5/4/17, 3/8/17, 2/8/17, 1/6/17, 12/9/16, 7/14/16.

Based on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to provide adequate supervision for safe smoking for one of 14 residents reviewed (Residents R1), who tended to burn his fingers with cigarettes, creating a situation in which the resident's safety was in Immediate Jeopardy, and failed to ensure that smoking safety assessments were completed according to the facility's policy for four of 14 residents reviewed (Residents R1, R5, R8, R9). Findings include: The facility's smoking policy, dated 2015, indicated that residents who wished to smoke tobacco were to be assessed for their ability to safely do so independently or with supervision/assistance. Upon admission, readmission, annually and with a significant change in condition, residents who wish to exercise their right to smoke would be assessed by a licensed staff member for their ability to do so. Based on the assessment tool, the resident would be deemed as requiring supervision/assistance when smoking or able to smoke independently. An occupational therapy evaluation for Resident R1, dated August 2, 2016, revealed that the resident sustained [REDACTED]. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated August 2, 2016, indicated that the resident was alert and oriented, had limited range of motion to the upper and lower extremities, and was dependent or required extensive assistance with activities of daily living. A smoking care plan, dated February 3, 2016, revealed that the care plan did not address the resident's safety while smoking. A smoking evaluation for Resident R1, dated May 23, 2016, revealed that the resident was safe to smoke independently. A nursing note, dated August 10, 2016, revealed that the resident had cigarette burns to the left fingers. An occupational therapy note, dated October 12, 2016, revealed that the resident tended to burn his fingers with cigarettes, and therapy was to determine a positioning device to assist with holding a cigarette to decrease the risk of burns to his fingers. On October 25, 2016, the resident was discharged from therapy due to refusing to change habits or to use adaptive equipment. However, there was no documented evidence that any interventions were put into place to ensure that the resident was safe while smoking, and that a smoking safety evaluation was completed until December 8, 2016, which revealed that the resident required supervision while smoking. Interview with the Director of Therapy on December 9, 2016, at 11:30 a.m. revealed that therapy recommended smoking assistance for Resident R1, but the resident refused and was discharged from therapy on October 25, 2016. Observations of Resident R1 on December 8, 2016, at 4:55 p.m. revealed that the resident was outside in the courtyard, and he was smoking without supervision. Interview with Resident R1 on December 8, 2016, at 6:30 p.m. revealed that he was smoking a non-filtered cigarette a couple months ago, and the cigarette burned down to his fingers and burned his fingers. Interviews with the Nursing Home Administrator and Assistant Director of Nursing on December 8, 2016, at 5:30 p.m. and December 9, 2016, at 2:45 p.m. confirmed that a smoking assessment should have been completed for Resident R1 on August 10, 2016, when the nurse noticed a burn on his finger. On December 8, 2016, at 6:07 p.m. the Nursing Home Administrator was informed that the health and safety of residents who were not provided with the required supervision to smoke was in Immediate Jeopardy. The facility submitted and implemented a plan to ensure the residents' safety by completing smoking assessments for all residents who smoked, monitoring all residents to ensure that the facility's smoking policy was followed, and re-educating the residents and the staff on the facility's smoking policy, including observations of the skin of smokers. The Immediate Jeopardy was removed on December 9, 2016, at 3:10 p.m. A nursing note for Resident R5, dated November 29, 2016, revealed that the resident was admitted to the facility on [DATE]. A psychosocial assessment, dated December 2, 2016, revealed that the resident was a current tobacco user. However, there was no documented evidence that a smoking assessment to determine the resident's safety with smoking was completed until December 8, 2016, nine days after admission to the facility, and the resident's current care plan revealed that the plan did not address the resident's safety with smoking. A comprehensive MDS assessment for Resident R8, dated October 22, 2016, revealed that the resident was admitted to the facility on [DATE], was alert and oriented, and required assistance with his care. A psychosocial assessment, dated October 20, 2016, revealed that the resident was a current tobacco user. However, there was no documented evidence that a smoking assessment was completed until December 8, 2016, 54 days after admission to the facility, and the resident's current care plan revealed that it did not address the resident's safety with smoking. A quarterly MDS assessment for Resident R9, dated November 2, 2016, revealed that the resident was admitted to the facility on [DATE], that she was able to make herself understood and could understand others, and she required assistance with her care. A psychosocial assessment, dated July 13, 2016, revealed that the resident was a current tobacco user. However, there was no documented evidence that a smoking assessment was completed until December 8, 2016, 149 days after being admitted to the facility. Interview with the Registered Nurse Assessment Coordinator on December 9, 2016, at 2:30 p.m. confirmed that the residents' care plans did not address safety while smoking and they should have. Interviews with the Nursing Home Administrator and Assistant Director of Nursing on December 8, 2016, at 5:30 p.m. and December 9, 2016, at 2:45 p.m. confirmed that smoking assessments were not completed timely for the above residents, and they were not aware that smoking assessments were not being completed timely. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 9/15/15. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 1/4/16, 8/10/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/14/16, 1/4/16, 10/1/15, 9/15/15, 8/10/15, 6/18/15, 9/15/15.

Based on review of policies, clinical records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that each resident had an individualized plan of care to meet his/her psychosocial needs for one of 40 residents reviewed (Resident CR1). Findings include: The facility's current policy regarding behavior management, undated, indicated that when a resident exhibits behaviors that are out of the ordinary for themselves and/or that may affect others negatively, the adverse behaviors were to be addressed immediately. Attempts were to be made to redirect the behavior and the staff were to develop a care plan to address the resident's behaviors. A [DIAGNOSES REDACTED]. A Minimum Data Set assessment (MDS - a required assessment of a resident's abilities and care needs), dated June 24, 2015, indicated that the resident was alert but had short and long term memory impairments, was incontinent of urine and bowel, required extensive assistance for hygiene, and had physical behaviors directed toward others during one to three days of the assessment period. The physician's orders [REDACTED]. The physician gave an order to start 5 milligrams (mg) of [MEDICATION NAME] (antipsychotic medication) half an hour before the resident's daily morning care. Nursing notes, dated May 15, 2015, indicated that the physician was contacted by the nursing staff to pursue if the [MEDICATION NAME] ordered prior to hygiene could be switched to benzodiazepines ([MEDICATION NAME] - an antianxiety medication). physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED] There was no documented evidence that the resident's behavior of kicking during care was assessed for possible causative factors or that a care plan with non-medication interventions was developed to assist the staff in attempting to prevent the behavior, and/or to appropriately intervene when the resident exhibited the behavior. The resident's care plan regarding behavior, dated December 22, 2014, revealed no evidence of an individualized plan to address the resident's kicking behavior. Review of information submitted by the facility, dated July 10, 2015, indicated that a nurse aide was providing care to Resident CR1, at which time the resident started kicking. The nurse aide then placed her hand below the resident's right knee and held his leg down to stop him from kicking and to complete the care. While holding the resident's leg down, the aide heard a pop and Resident CR1's roommate stated that he heard Resident CR1 cry out. X-rays completed on July 9, 2015, and hospital records, dated July 10, 2015, revealed that the resident was diagnosed with [REDACTED]. Interviews with the Director of Nursing on August 10, 2015, at 12:15 p.m. and 1:10 p.m., confirmed that after Resident CR1's behavior of kicking during care was identified in May 2015, and the resident was started on routine [MEDICATION NAME] prior to care, no changes were made to the resident's care plan to address the kicking behavior. 28 Pa. Code 211.11 (d) Resident care plan. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 6/18/15, 5/15/15, 1/28/15, 12/3/14, 8/21/14.