Every finding on record at Trillium Place

Based on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for one resident reviewed (Resident 1). Review of facility policy titled Medication Administration-General Guidelines, last revised July 1. 2025, documents medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive, considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication.Review of Resident 1's physician orders revealed an order dated September 23, 2025, for Comfort Care Hospice consult.Review of Resident 1's progress notes revealed a social service note dated September 23, 2025, documenting Resident 1 was admitted to Hospice and Community Care with a medical diagnosis of Cerebrovascular Accident (when blood flow to a part of the brain is interrupted).Review of Resident 1's physician orders revealed an order dated September 22, 2025, for Lorazepam (a medication used to treat anxiety, nausea, agitation, and insomnia) tablet 0.5 milligrams (mg), one tablet by mouth every 6 hours as needed for anxiety for 14 days.Review of facility records revealed an investigation statement signed by Registered Nurse Employee E3, dated September 29, 2025, documenting at 3:00 p.m., while getting a report from Nurse Aide Employee E4, Employee E4 stated Resident 1's family requested Lorazepam be administered to the resident. Employee E3 told Employee E4 that the Lorazepam could be administered to Resident 1 with his/her 4:00 p.m., scheduled medications. A second request was made directly to Employee E3 by the family at 3:10 p.m.Per Employee E3's statement Resident 1's representative approached Employee E3 at 3:10 p.m. and stated that he/she had requested Ativan for the resident at 2:30 p.m. and Resident 1 still had not received it. Employee E3 replied that he/she would give the medication to Resident 1 now if the representative wanted then stated but if he/she is dead in an hour don't blame me.Review of Resident 1's Controlled Drug Receipt Record/Disposition Form revealed the Lorazepam was administered September 29, 2025, at 3:35 p.m.Further review of Resident 1's Controlled Drug Receipt Record/Disposition Form revealed the Lorazepam was last administered to the resident on September 27, 2026, at 9:50 a.m., indicating administering the medication when initially requested by the family fell within the prescribed timeframe. Employee E3 failed to provide the as needed medication when family felt it was needed.Interview conducted with the Nursing Home Administrator (NHA) on April 20. 2026, at 2:26 p.m., when the above information was presented the NHA confirmed the above did occur. The NHA stated Employee E3 was counseled and educated regarding conduct and policy violations. 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) Nursing Services

Based on clinical documentation and staff interview it was determined that the facility failed to protect the resident's right to be free of any type of abuse, including mental abuse, for one of four residents reviewed (Resident R1). Findings include: Review of facility documentation revealed that the facility was informed on October 2, 2020, at 4:30 p.m., of a social media video post involving Resident R1. The video documented Resident R1 touching Employee E1's breasts, and another staff member, eventually identified as Employee E2, heard laughing in the background. Review of clinical record documentation, specifically the MDS (minimum data set), revealed that Resident R1 had a BIMS (brief interview for mental status) of 10 out of 15, on August 13, 2020, indicating moderate cognitive impairment. Per the facility, a BIMS was completed immediately following the incident that resulted in a score of 4 out of 15, indicating severe cognitive impairment. Review of clinical documentation revealed the resident's care plan contained a problem of sexually inappropriate behavior and contained interventions to redirect those behaviors. Review of facility documentation revealed family notification of incident on October 2, 2020. Facility reported that resident's spouse commented he was very frisky with daughter on visit today. Review of facility documentation revealed Employee E1 was suspended on October 2, 2020, and then terminated at the conclusion of the investigation, due to violation of the facility policy titled HIPAA and Compliance Policy 28, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings. Review of facility documentation revealed that Employee E2 was identified during the investigation as the employee laughing in the background, and was terminated due to not intervening, and violating the facility policy titled HIPAA and Compliance Policy 28, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings. The facility provided documentation that education was provided to all staff, with employee signatures, after the incident. Staff education was completed on October 10, 2020, and included education on the following topics: freedom from abuse, what causes sexually inappropriate behavior in dementia, electronic and social media, and cell phone use. An interview with staff Employee E3, on October 30, 2020, at 10:35 a.m., confirmed the education as described above was provided. Interview with the Nursing Home Administrator on October 30, 2020, at 1:00 p.m., confirmed the above incident did occur. However, there was no evidence to demonstrate that the facility conducted any type of follow up to the education to determine that staff were following the facility HIPAA and Compliance Policy 28, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recordings. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 2/26/19, 4/11/19, 10/28/19 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 2/26/19, 4/11/19, 10/28/19 28 Pa. Code 201.29(c)(d) Resident rights Previously cited 10/28/19 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/27/17, 2/26/19, 10/28/19 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 2/26/19, 4/11/19, 3/12/20

Based on clinical record review, facility documentation, facility policy review, and staff interview, it was determined that the facility failed to ensure that only the appropriate medications, as ordered by the physician, were administered to a resident, for one of one resident reviewed (Resident 59). Finding include: Review of the facility policy titled Administering Medication, revealed in section number twenty-three: medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Review of Resident 59's clinical record revealed [DIAGNOSES REDACTED]. degeneration (blurred or no vision in the center of the visual field); [MEDICAL CONDITION], stage III (gradual loss of kidney function); [MEDICAL CONDITION] (major blood vessels that supply your heart with blood, oxygen and nutrients (coronary arteries) become damaged or diseased); and [MEDICAL CONDITION] (narrowed arteries in the heart). Review of Resident 59's clinical record revealed an MDS (minimum data set -periodic assessment of residents abilities and needs) dated January 15, 2020 which indicated a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating intact cognitive function. Review of Resident 59's clinical record revealed a nursing progress noted dated January 24, 2020, (2:07 a.m.) This writer alerted to resident room r/t to report he wanted to speak to RN. Resident reported to staff and this writer he received an injection in his abdomen this evening and he did not know what it was for. Resident abd w/o notation of injection site or bruising. Resident denies ill effects, Cognition at baseline. Awake and alert w/ reporting. Resident room mate receives insulin in the evening. Resident Blood sugar at this time noted 115. Resident placed on Focused observation for blood sugar monitoring. Continued review of Resident 59's nursing progress notes revealed note dated January 24, 2020, (2:47 a.m.) On call MD (physician) updated on suspected insulin injection. N.O (New Order) received to monitor Blood sugar q(every) 1 hour until PCP (primary care physician) updated. Give snack (resident w/ (candy) at bedside and reports snacking on them, as well as observed by staff eating (candy). Call the on call (physician), if resident blood sugar below 115. Continued review of clinical notes revealed note (4:19 a.m.) On call MD notified of 0300 & 0400 bedside blood glucose. N.O. (New order) Serum Insulin & BMP (basic metabolic panel - used to check the status of a person's kidneys and their electrolyte and acid/base balance, as well as their blood glucose level, all of which are related to a person's metabolism) in am. Resident continues to be awake and alert w/ encounters at bedside. Further review of progress noted revealed note dated January 24, 2020 (3:31 p.m.) Blood sugars 7-126, 8-135, 9-140, 10-146, 11-122, 12-119, 13-131, 14-126. Resident remains asymptomatic. Review of Resident 59's January, 2020, physician orders failed to reveal any orders for insulin to be administered. Further review of the physician orders failed to reveal a [DIAGNOSES REDACTED]. Review of facility documentation labeled medication/Fluid error event, stated that a drug by the name of Lamtis ([MEDICATION NAME]) was injected by a dosage 42 units into the wrong resident. Continued review of facility documentation revealed an investigation statement obtained via telephone contact on January 24, 2020, at approximately 4 p.m. with licensed Employee E3 I was very flustered that evening. I had a lot going on with several interruptions. It is possible that I could have administered the [MEDICATION NAME] to the wrong resident. I am aware of the medication checks needed for safety. I did perform them with giving the pills but I went back and got the insulin and could have mixed up who was to be receiving it. Interview conducted on March 13, 2020, at approximately 11:20 a.m. with the Director of Nursing when the above information was presented and the Director of Nursing confirmed the incident was of a significant medication error. 28 Pa Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, job descriptions, documentation, clinical record, staff interview, and coroner report, it was found that the facility failed to protect residents from neglect which resulted in actual harm to resident CL1, who was improperly transferred in a lift, fell , and sustained head and neck trauma resulting in death for one of two residents reviewed (Resident CL1). Findings include: Review of facility policy Full Body Lift Resident Transfers, last revised August 2015, revealed Floor lift requires two (2) trained care giving staff members. Review of the job description for caregiver revealed: Proper use of mechanical lifts requires 2 staff for all transfers. The job description was acknowledged and signed by nursing assistant Employee E5 on December 5, 2018. Review of nursing assistant Employee E5's facility orientation revealed that Employee E5 signed that they received training on resident transfers and mechanical lifts on December 19, 2018. Review of Resident CL1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident CL1's care plan identified the resident as requiring staff assistance to complete activities of daily living due to mobility deficits resulting from [MEDICAL CONDITION] with an intervention for staff to utilize a hoyer lift with two staff members for transfers per therapy recommendations. Review of Resident CL1's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) from June 26, 2019 revealed the resident was totally dependent on two staff persons for transfers. Review of Resident CL1's progress notes revealed a nurse's note dated September 8, 2019 which stated: Received call from LPN ((licensed practical nurse)) at 10:30 that there was an emergency on the floor and to come up right away. This RN ((registered nurse)) and other RN supervisor ran up and immediately were on unit. We were directed to (Resident CL1's) room. Upon entering resident's room, noted resident to be seated in her wheelchair. Her head was tilted back, her eyes were closed, she's unresponsive and mouth was open. Observed resident take one shallow breath. This RN ran to confirm code status which is DNR/comfort ((do not resuscitate)) and ran back to resident's room. No further breathing noted from resident. Asked LPN if resident was a stroke alert, she said no. Assessed pupils which were fixed and dilated. Assessed head for injuries. PO2 ((pulse oximetry - measure of the amount of oxygen in the blood. Normal is 95-100)) was 62 and falling. Resident's apical heart rate was 16 ((normal is 60-100)) and sporadic. Continued to assess resident who had absence of breath sounds. Noted small skin tear to resident's (left) shin which had scant amount of blood that had clotted. Resident was transferred to bed via hoyer lift and 3 assist for further assessment. No other injuries noted. Resident remained without respirations, unresponsive, pupils remained fixed and dilated. Her apical heart rate at that time was 6 beats per minute and remained slow and irregular. Her heart rate slowed again at around 11:12 to 4 beats per minute and she passed away at 11:15 when she had an absence of a heart beat x 2 minutes. Family aware. Social work aware. (Director of Nursing) aware. (Medical director) aware. Review of statement from nursing assistant Employee E5 revealed that on September 8, 2019 Employee E5 transferred Resident CL1 alone while (nursing assistant Employee E13) was trying to keep other resident calm in hallway. When I went to transfer resident the sling top string came unloose. I then lower resident to the floor and her back hit the pole of the hoyer lift. The reasoning for my action was because I had another resident very upset and needed to use the bed pan. Review of statement from nursing assistant Employee E13 on September 8, 2019 revealed: (Employee E5) told me she needed help getting someone up. We walked down the hall, (Employee E5) said she was going to .get (Resident CL1) ready. I was on the computer. I heard a resident making growling sounds, and there was another resident sitting in the hall that said it sounds like someone fell in there .I walk in the room, the curtain is pulled, I can see something on the floor. I opened the curtain and the resident was on the floor with her head up against the wheel of the wheelchair with a pillow behind her head. (Nursing assistant E5) was hooking her up to the lift and she put her in the wheelchair. I said .is the resident usually not responsive and doesn't talk? (Employee E5) answered yes. I went and got (Licensed Nurse Employee E12.) When I seen the resident on the floor she had bubbles coming out side of her mouth and was humming. When I was on the computer, (Employee E5) never said she was ready to transfer. Resident was not connected to the lift when I opened the curtain. Review of statement from licensed nurse Employee E12 on September 8, 2019 revealed: At approximately 10:20 a.m. on 9/8/19, I was notified by (Employee E13) .that she had walked into (Resident CL1's room) and observed (the resident) on the floor beside her wheelchair. (Employee E5), who had been assigned to care for (Resident CL1) on this shift was attempting to put the hoyer lift pad under (the resident) according to (Employee E13.) At this time, (Employee E5) walked up to me and asked me if (Resident CL1) had a history of [REDACTED]. She looked pale on her face. I touched her on her shoulder and called her name, she did not respond to me. I immediately left the room .to call and notify my supervisor. Review of statement from licensed nurse Employee E14 on September 8, 2019 revealed Asked (Employee E5) what happened and she made statements about a strap coming loose and she tried to lower the resident to the floor but the resident had hit her buttocks hard on the floor. She stated she wasn't sure if resident had hit her head. Review of statement from licensed nurse Employee E15 on September 8, 2019 revealed Questioned (Employee E5) involved in incident who said resident was alert and talking prior to transfer. She said she was in a hurry and transferred the resident by herself. She was transferring resident when she noticed one of the straps wasn't fully hooked and resident began to fall. She said she tried to lower her to the floor and resident's (buttocks) hit off the floor. When asked if resident hit her head she said 'I don't think.' Interview with the Medical Director on September 20, 2019 at 12:10 p.m. revealed that he was Resident CL1's physician at the time of the resident's death. The medical director further stated that he was not aware of any decline in the resident's condition prior to September 8, 2019 and had received no concerns from the staff prior to September 8, 2019. Interview with the Nursing Home Administrator (NHA) on September 20, 2019 at 12:30 p.m. revealed that the deputy coroner stopped by the facility on September 9, 2019 and gave verbal confirmation that Resident CL1 sustained a C6 fracture (neck fracture) and that the cause of death would be listed as head and neck trauma/injury. The NHA confirmed that nursing assistant Employee E5 made a stupid mistake by not following facility policy and transferring Resident CL1 without the assistance of another staff person. Review of the official coroner's report, requested by the Department, and received on October 28, 2019 revealed that the cause of Resident CL1's death was traumatic head and neck injury, with the manner of death ruled accidental. The above information was conveyed to the Director of Nursing on October 28, 2019. The facility failed to ensure Resident CL1 was free from neglect, evidenced by the resident being improperly transferred by nursing assistant Employee E5 and sustaining a traumatic head and neck injury and subsequently dying. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 2/26/19, 4/11/19 28 Pa. Code 201.18(b)(1)(3)(e)(1) ManagementPreviously cited 10/27/17, 2/26/19, 4/11/19 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policiesPreviously cited 10/27/17, 2/26/19 28 Pa. Code 211.11(d) Resident care planPreviously cited 2/26/19 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 10/27/17, 2/26/19, 4/11/19

Based on observations, staff and resident interviews and review of clinical records, it was determined that the facility failed to ensure that call bells were accessible for residents on three of 38 residents on the third floor. (Resident A2, Resident A5 and Resident C5) Findings include: Review of Resident A2's falls care plan (created (MONTH) 6, 2019) revealed, Place my call bell within reach. Observation on (MONTH) 11, 2019 at approximately 9:35 a.m. of Resident A2 (Bed A) revealed Resident A2's call bell button was clipped on the right side of the bed on edge of mattress (above head part). Interview of Resident A2 on (MONTH) 11, 2019 at 9:35 a.m. revealed that Resident A2 was not aware of the location of his call bell button and once made aware was unable to reach it. Review of Resident A5's falls care plan (created (MONTH) 11, 2019) revealed, Place my tap bell within reach. Observation on (MONTH) 11, 2019 at approximately 9:30 a.m. of Resident A5 (Bed A) revealed Resident A5 has a tap bell on the tray table not within reach. Furthermore, observation revealed that Resident A5 was lying on her right side supported by a wedge pillow while tray table with tap bell was positioned on left side of the bed unable to reach call bell. Interview of Resident C5 on (MONTH) 11, 2019 at approximately 9:45 a.m. revealed, There maybe once a week, it is left in the bed while I was in recliner, I can't get it. Interview of Licensed Employee E1 on (MONTH) 11, 2019 at 9:38 a.m. confirmed that tap bell of Resident A5 and call bell button of Resident A2 was not accessible. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 2/26/19 28 Pa. Code 201.18(b)(1) Management Previously Cited 2/26/19, 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously Cited 2/26/19

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive baseline care plan for one of three residents reviewed (Resident #211). Findings include: Review of Resident #211's nursing assessment dated (MONTH) 20, 2019, revealed that the resident was admitted to the facility on (MONTH) 19, 2019, with admitting [DIAGNOSES REDACTED]. difficile) {infectious bacterium that causes diarrhea and more serious intestinal conditions} for which the resident was on contact precautions (series of procedures designed to minimize the transmission of infectious organisms by direct or indirect contact with an infected patient or his environment) and end stage [MEDICAL CONDITIONS] {last stage of [MEDICAL CONDITION]} necessitating transport to [MEDICAL TREATMENT] (treatment for [REDACTED]. Review of the resident's baseline care plan dated (MONTH) 19, 2019, revealed no documented interventions related to the resident's [DIAGNOSES REDACTED]. The aforementioned findings were reported to the Nursing Home Administrator and Director of Nursing on (MONTH) 26, 2019, at approximately 12:00 p.m. Refer to F880. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 10/27/17

Based on observation, review of facility policy, clinical record review and staff and resident interviews, it was determined that the facility failed to ensure safe infection control practices were followed for contact precautions for one of two residents reviewed (Resident #221). Findings include: Review of facility policy titled Contact Precautions, dated (MONTH) 7, 2019, revealed that: Whenever a roommate is present, keep the privacy curtain pulled between beds; Residents with the same organism should be cohorted whenever possible at the discretion of the Infection Preventionist designee, Director of Nursing or Medical Director; When determining resident placement consider epidemiology of the microorganism and the resident population; Place sign on the door, indicating to stop and check with nursing before entering the room; Clean, personal protective equipment (PPE) cart is placed outside of the room. Review of resident's admission assessment dated (MONTH) 15, 2019, revealed the following: The resident was admitted on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. difficile) {infectious bacterium that causes diarrhea and more serious intestinal conditions}and [MEDICAL CONDITION] (brain disease, damage, or malfunction). The resident's Brief Interview of Mental Status (BIMS) score was four, which indicates severely impaired cognition. The resident was indicated as having frequent bowel incontinence. Review of the resident's initial and active care plan for [DIAGNOSES REDACTED]icile revealed that the resident would be provided with a bedside commode. Review of nursing notes from admission revealed the following: On (MONTH) 8, 2019, the resident arrived at the facility from the hospital with contact isolation set up due to [DIAGNOSES REDACTED]icile. On (MONTH) 9, 2019, the resident was noted to be oriented to person only and was incontinent and continent of bowel, was very confused and came out of her room multiple times during the night without her pants or underwear. On (MONTH) 15 and 16, 2019, the resident was incontinent of bowel. On (MONTH) 16, 2019, the resident was noted by staff to be very unsanitary with not washing hands and using shared bathroom with roommate and that resident also attempted to get into the kitchen independently this shift. Additionally it was noted that staff attempted to assist resident to wash her hands after every toileting event with no success. On (MONTH) 17, 2019, it was noted that staff had found the resident in the dining room eating potato chips which she had obtained from the cabinet on her own. Again on this date it was noted that staff attempted to assist resident to wash her hands after every toileting event with no success. On (MONTH) 18, 2019, it was noted that staff observed the resident standing in her room with her pants down around her ankles, at which time, staff assisted the resident into the bathroom as she told them she needed to move her bowel. Staff later found the resident in the bathroom seated on the bedside commode, on a towel, which was on the lid of the commode. The resident was incontinent of bowel on the towel and in her brief. Interview with Employee E3, licensed staff Case Manager for Infection Control, on (MONTH) 25, 2019, at 9:30 a.m. revealed that on (MONTH) 15, 2019, she was contacted by admissions to determine if it would be o.k. to admit Resident #214 to Resident #221's room, even though Resident #221 was on contact precautions. Employee E3 stated she told admissions that it was preferable to keep Resident #221 alone in the room but that it would not be prohibitive to place Resident #214 in Resident #221's room. The interview further revealed that she did not believe there was another rehabilitation unit room available for Resident #214 due to the facility's need to forecast admissions for residents from the facility community who were currently in the hospital and would need to be admitted to the skilled unit. When asked if Resident #214 could have been admitted to another unit in the facility, Employee E3 stated she did not know how admissions handled that situation. Employee E3 stated that she educated the staff in the rehabilitation unit on caring for residents on contact precautions but stated that to her knowledge no one had spoken to Resident #214 about being placed in a room with a roommate on contact precautions. Review of the five day assessment for Resident #214 revealed a BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. Interview with Resident #214 on (MONTH) 25, 2019, at approximately 11:30 a.m. revealed that she was admitted for skilled rehabilitation on Friday, (MONTH) 15, 2019, at approximately 4:30 p.m. from the hospital where she had a right total knee replacement resulting in a surgical wound. The resident stated that she realized she was placed in a room with someone on precautions as she observed the sign on the door, the equipment cart outside the room and the staff wearing a gown whenever they cared for her roommate. This resident stated that she did not think it was best practice to place her in this room but was just hoping that with hard work in therapy she would be able to be discharged soon to her home. She also stated that she saw that Resident #221 had a portable commode but that the resident would frequently go into the bathroom on her own and that staff would use the bathroom to clean the resident up after she had an accident with her bowel and that staff had told her that they sanitize the bathroom after each incident. Resident #214 stated that she put up with all the yelling at night and her feeling that it wasn't best practice to have her in that room but then when she overheard staff talking in the bathroom and they said I don't know why they put her in this room, she decided to ask for a room transfer. Resident #214 stated that she was moved on Saturday, (MONTH) 23, 2019, a week after her admission. Review of the census for (MONTH) 15, 2019, for all units except the two locked units, revealed that the facility had five empty semi-private female beds The aforementioned findings were reported to the Nursing Home Administrator and the Director of Nursing on (MONTH) 26, 2019, at approximately 12:00 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 10/27/17 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/27/17 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 10/27/17

Based on observation, it was determined that the facility failed to maintain and promote residents' dignity during meals in two of nine dining rooms observed. (Eshelman Run and Goods Run) Findings include: Observation conducted of the Eshelman Run dining service on October 25, 2017 at approximately 5:08 p.m., revealed that Resident P4 was seated at the table for the dinner meal with Resident P5. Resident P5 was served her dinner plate at 5:08 pm. Resident P4 was not served her dinner plate until 5:21 p.m. Observation of Goods Run dining service on October 25, 2017 at approximately 5:30 p.m. revealed that Resident R6 had dinner plate but unable to eat without assistance. Further observations revealed that Resident R6 was not assisted to eat the dinner meal by nursing staff, Employee E5 until 5:40 p.m. 10 minutes from when the resident was served her dinner meal. The facility failed to promote the dignity of Resident P4 and R6 dignity during meal time. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 05/17/16, 04/17/17 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 05/17/16, 04/17/17

Based on review of the clinical record, facility documentation, staff interview and facility policy, it was determined that the facility failed to provide an intervention timely to prevent the reoccurrence of an accident with hot liquid for two out of 27 residents reviewed. (Resident H1 and G7 ). Findings include: Review of facility policy entitled Incident and Accident Notification and Investigation (6/15/2015) revealed that investigations are completed to identify the cause of an injury and ensure that further injury is prevented. Review of Resident H1's [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS (minimum data set: a periodic assessment of the resident's care needs) dated August 24, 2017 revealed a BIMS (brief interview for mental status) of 11 out of 15 which identified the resident with moderate cognitive impairment. Review of Resident H1's nursing's notes dated September 5, 2017 at 3:11 p.m. revealed that this morning, resident took off lid from her hot cup of tea and ended up spilling some tea on her abdominal area and on the (R- right) side of her torso. An assessment of the resident's skin revealed that there was no blistering or redness. Review of facility investigation into the incident of September 5, 2017 revealed that the incident was not investigated by the facility until September 22, 2017, 17 days later when it was suggested that occupational therapy be consulted. Further review of facility investigation revealed that a therapy screen was not requested until October 9, 2017, a month after the hot liquid spill occurred. Interview with the Director of Nursing on October 26, 2017 at 11:30 a.m. revealed that there was no reason stated as to the delay in putting an intervention in place to prevent the resident for spilling a hot beverage on herself. Review of Resident G7's nursing notes dated July 24, 2017 revealed that the resident had spilled coffee with creamer during the lunch meal onto her right thigh. An assessment of the resident's skin revealed that there was no redness or no blistering and the resident had pain. There was no documented evidence that interventions were put in place to prevent a further re occurrence of the resident spilling a hot beverage on herself. Further review of nursing notes revealed that on July 28, 2017 Resident G7 had a second incident of spilling coffee onto her right thigh. An assessment of the resident's skin revealed that there was no redness and a referral was made for the resident to be screen by occupational therapy. Interview with licensed nursing staff, Employee E7 on October 26, 2017 at approximately 12:20 p.m. confirmed that there was no intervention put in place until the July 28, 2017 incident occurred. 28 Pa. Code: 201.18 (b)(1)Management 28 Pa. Code 211.10 (d) Resident Care Policies Previously cited: 5/17/16, 4/17/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 05/17/16, 4/17/2017

Based on observation, it was determined that the facility failed to maintain proper infection control procedures on 3 of 8 nursing units. (Jackson Run, Lititz Run and Goods Run) Findings Include: Observation of(NAME)Run on October 24, 2017 at approximately 10:00 a.m. revealed a digital thermometer place on top of the garbage container to the right side of the medication cart and a metal pill crusher on top of the hazard waste container. Observation of Lititz Run on October 25, 2017 at approximately 12:35 p.m. revealed a digital thermometer on top of the lid of the garbage container of the medication cart. Observation of(NAME)Run on October 25, 2017 at approximately 12:40 p.m. revealed a digital thermometer on the on top of the lid of the garbage container of the medication cart and a metal pill crusher on the top of the hazard waste container. Observation of the lunch meal in Goods Run on October 25, 2017 at approximately 12:44 p.m. revealed that nursing staff, Employee E4 was feeding Resident Q8 then proceeded to Resident R9 to wipe her mouth, give her a drink and assist her hand with repositioning of spoon. Employee E4 then returned to assisting Resident Q8 with her lunch time meal, without washing hands prior to resumption of duties. During same observation period on October 25, 2017, surveyor observed Employee E3 assisting Resident R6 with her meal then proceeded to assist Resident R9 with her drink and straw placement as well as wiping the mouth after beverage. Employee E3 returned to assisting Resident R6 with her meal but failed to wash hands before resumption of feeding assistance. 28 Pa. Code 211.10 (d) Resident Care Policies Previously cited: 5/17/16, 4/17/17 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited: 5/17/16, 4/17/17

Based on review of facility policy, review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to ensure that four of 26 residents reviewed, remained free of significant medication errors, which resulted in Resident CL1 who received the wrong medications, requiring transfer to the hospital and treatment for [REDACTED]. Findings include: Review of the facility policy entitled, Medication Administration, reviewed/revised on July 24, 2015, revealed that all medications shall be administered in compliance with State and Federal Laws. The nurse when administering medication should make sure, the resident is identified prior to administration of a medication. Review of the facility's protocols titled, Medication Assistance, undated, revealed that when administering medications please note the following for whom you are administering medications to: resident's name and picture. Review of, The 8 Rights of Medication Administration, undated, revealed that medications are administered in accordance with the following rights of medication administration - right person, right medication, right dose, right time, right route, right documentation, right reason and right response. Review of Resident CL1's closed clinical record revealed that the resident was admitted to the facility on [DATE]. Hospice (end of life care) services were initiated for Resident CL1 on October 5, 2015. Review of Resident CL1's February 2017 physician's orders revealed [DIAGNOSES REDACTED].), hypertension (elevated/high blood pressure), [MEDICAL CONDITION] (CAD - narrowing of the blood vessels which supply the heart with blood and oxygen) and spinal stenosis (a narrowing of the spinal canal). Review of Resident CL1's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated December 14, 2016, indicated that the resident had moderate cognitive impairment and a BIMS (Brief Interview for Mental Status - a tool used to assess a residents cognitive status) score of 10 out of 15 (a score of 8 to 12 indicates moderately impaired.) Review of information dated March 14, 2017, submitted by the facility indicated that on March 14, 2017, at 7:30 a.m. Resident CL1 was incorrectly administered Resident D5's medications which consisted of [MEDICATION NAME] 20 milligram (a medication used to decrease the amount of acid the stomach produces), Senna S one tablet (for constipation), [MEDICATION NAME] 0.2 milligram (a medication used in the treatment of [REDACTED]. generalized pain), Cranberry tablet 450 milligram (used to lower risk of repeated UTIs -Urinary Tract Infections) and [MEDICATION NAME] 10 milligram (a medication used in the treatment of [REDACTED]. Further review of the information submitted by the facility revealed that on March 14, 2017, at 7:30 a.m., (Resident CL1) was given (Resident D5's) AM (morning) medications. Resident was being monitored closely. Resident remained alert and able to verbalize. Physician made aware. Residents blood pressure went from 109/80 to 74/38 within 30 minutes of administration. Order to send resident to emergency room obtained from physician. Power of Attorney made aware and would like resident treated in the emergency room . Review of Licensed Nurse, Employee E3's, interview statement obtained on March 17, 2017, at approximately 8:00 a.m. revealed that Employee E3, gave (Resident CL1) (Resident C5's) medications. She realized she gave the wrong medication to the wrong patient upon returning to the medication cart to sign off medication administration. Review of Resident CL1's nursing progress addendum note dated March 17, 2017, at 2:11 p.m. revealed that on March 14, 2017, Licensed Nurse, Employee E3, reported to Licensed Nurse, Employee E5, that wrong medication was administered around 0730 (7:30 a.m.). Employee E5, went to assess resident around 0800 (8:00 a.m.). No acute distress noted, resident stable. Vital signs 124/84 (blood pressure) , 86 (pulse), 24 (respiration) and 94% (pulse oxygen level) on 4 liters of oxygen. The attending physician was notified at 8:20 a.m., and a new order was obtained to hold all of the resident's morning medications, take hourly blood pressures and call the physician if needed. Further review of the nursing note revealed, At 0900 (9:00 a.m.), a blood pressure of 74/30 noted. Physician made aware, new order to send to ER (emergency room ) for evaluation and treatment. Review of the hospital documentation dated March 14, 2017, confirmed that the resident was diagnosed with [REDACTED]. An interview with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 2:30 p.m. confirmed that on March 14, 2017, at 7:30 a.m. Resident CL1 was given the wrong medication. The facility failed to ensure that the resident was free of a significant medication error consisting of five medications incorrectly administered to the resident, which resulted in the resident being transferred to the hospital with a [DIAGNOSES REDACTED]. Review of Resident Q1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident Q1's February 2017 physician's orders revealed an order dated February 14, 2017, for [MEDICATION NAME] Suspension (a [MEDICATION NAME][MEDICATION NAME] inhaler medication used to treat [MEDICAL CONDITION]) 0.5 milligrams/2 milliliters, (1 ampul) for nebulization (a device for producing a fine spray of liquid) two times daily. Review of nursing documentation dated February 15, 2017, at 3:42 a.m. revealed that the Registered Nurse was alerted to the resident's room with a concern regarding [MEDICATION NAME] ([MEDICATION NAME] - a diuretic medication) dose been administered. Review of Resident Q1's February 2017, Medication Administration Record [REDACTED]. Further review of Resident Q1's February 2017 Medication Administration Record [REDACTED]. The resident received a dose of [MEDICATION NAME] 0.5 milligrams on February 14, 2017, at 8:00 p.m. Further review of Resident Q1's February 2017 physician's orders revealed no physician order to discontinue the [MEDICATION NAME] and no physcian order for [REDACTED].>Review of facility documentation regarding the administration of [MEDICATION NAME] ([MEDICATION NAME]) to Resident Q1 without a physician's order for this medication revealed that [MEDICATION NAME] was entered into Resident Q1's February 2017 computerized medication record by Licensed Nursing Staff, Employee E4, at the time that it was delivered from the pharmacy and the medication was adminsitered to the resident on February 14, 2017, at 8:00 p.m. Further review of the facility documentation revealed that Employee E4, changed Resident Q1's physician's orders to [MEDICATION NAME] without clarifying with the physician or the pharmacy. An interview conducted on April 17, 2017, at approximately 12:30 p.m. with the Nursing Home Administrator and the Director of Nursing confirmed that Employee E4 entered in the computer system [MEDICATION NAME] instead of [MEDICATION NAME] Suspension because that was the medication sent by the pharmacy, which resulted in a significant medication error. Review of Resident Q15's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident Q15's December 2016 physician's orders revealed an order for [REDACTED]. Review of Resident Q15's nursing notes revealed a nurse entry on December 23, 2016, at 3:21 p.m. stating, Resident given [MEDICATION NAME] 20 mg instead of [MEDICATION NAME] 10 mg PRN (as needed) dose. Review of facility documentation revealed that on December 23, 2016, Employee E4, administered the resident's scheduled 8:00 a.m. [MEDICATION NAME] 20 mg extended release tablet, and then at 10:30 a.m. Employee E4 administered another [MEDICATION NAME] 20mg extended release tabled instead of the resident's as needed [MEDICATION NAME] 10 mg. The above was discussed and confirmed with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 12:30 p.m. Review of Resident R5's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R5's September 2016 physician's orders revealed an order dated September 23, 2016, for [MEDICATION NAME] (a fast acting insulin used to lower the body's blood sugar) 8 units with meals. Review of Resident R5's September 2016 Medication Administration Record [REDACTED]. Further review of Resident R5's September 2016 Medication Administration Record [REDACTED]. Review of facility documentation revealed that, Employee E4, transcribed the September 23, 2016, physician's order for [MEDICATION NAME] 8 units with meals incorrectly as [MEDICATION NAME] 8 units four times daily, causing Resident R5 to receive an extra 8 units of [MEDICATION NAME] at 8:00 p.m. on September 24, 2016. The above was discussed and confirmed with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 12:30 p.m. The facility failed to ensure that Residents Q1, Q15 and R5 were free of significant medication errors. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 05/17/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.9(a)(l)(d)(e) Pharmacy services 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 05/17/16 28 Pa. Code 211.12(c) Nursing services Previously cited 03/26/15 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 03/26/15, 05/17/16

Based on review of clinical record, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure a resident was timely assessed by the physcian after a change in condition for one of 26 residents reviewed (Resident L14). Findings include: Review of the facility policy entitled, Physician Notification Emergent and Non-Emergent, revised March 2017, revealed the following guidelines to notify the physician: The LPN (Licensed Practical Nurse)/Staff RN (Registered Nurse) contacts the RN Supervisor or RN Nurse Manager to report any acute change in the resident's condition; the RN assesses the resident and notifies the attending physician when the assessment indicates an acute change in condition may have occurred. Review of Resident L14's [DIAGNOSES REDACTED]. Review of Resident L14's nursing notes revealed that on August 20, 2016, at 8:48 p.m. Resident L14 complained of right wrist and hand pain. Further review of Resident L14's nursing notes revealed that on August 20, 2016, at 10:52 p.m. Resident L14's right wrist appeared slightly puffy (swollen). Review of Resident L14's nursing notes revealed that on August 21, 2016, at 1:05 p.m. Resident L14's right wrist continued to remain swollen and Resident L14 appeared, to have difficulty lifting arm up. On August 22, 2016, at 3:11 p.m. the nursing notes documented that Resident L14's right wrist and hand continued to remain swollen and the resident expressed pain when the wrist area was touched. Review of Resident L14's nursing notes dated August 23, 2016, at 10:00 a.m. revealed that the resident was, assessed due to ongoing swelling in right hand. Swelling noted to right hand and wrist. No redness noted. Slight increase in warmth noted in comparison to left hand and wrist. Resident does admit to hand being sore. Range of motion poor to this extremity. Resident barely able to lift hand. Certified Registered Nurse Practitioner (CRNP) on unit and notified of change. She will examine today. Physician's documentation dated August 23, 2015, at 10:30 a.m. confirmed that the resident was assessed by the CRNP on August 23, 2015, which was three days after the initial discovery of the resident's wrist pain and swelling. An interview with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 11:10 a.m. confirmed that the physician and/or the CRNP did not assess Resident L14's wrist pain until August 23, 2016. The facility failed to ensure that Resident L14 was assessed after experiencing pain and swelling of the right wrist in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 05/17/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 03/26/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 05/17/16 28 Pa. Code 211.12(c) Nursing services Previously cited 03/26/15 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 03/26/15, 05/17/16

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy services provided the correct medications and the availability of an insulin medication for two of 26 residents reviewed (Residents R5 and Resident Q1). Findings include: Review of Resident Q1's February 2017 physician's orders [REDACTED].) Review of the facility documentation revealed that instead of Budesonide, the pharmacy sent to the facility Bumetanide (Bumex-a diuretic-water pill) 0.5 milligrams. Review of the Resident Q1's physician's orders [REDACTED]. Review of Resident R5's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R5 September 2016 physcian's orders revealed an order for [REDACTED]. Review of Resident R5's nursing notes revealed a nurse entry on February 18, 2017, which stated, Novolog not available. Pharmacy notified at 0900 (9:00 a.m.) for refill. 1200 (12:00 p.m.) dose held due to no dose available and resident refused meal. Will continue to observe. Refill faxed again to pharmacy. An interview with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 12:30 p.m. confirmed that the facility did not ensure that Novolog was readily available for Resident R5. The facility failed to ensure the availability of an insulin medication for Resident R5. The above was discussed and confirmed with the Nursing Home Administrator and the Director of Nursing on April 17, 2017, at approximately 12:30 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/17/16. 28 Pa. Code 201.18(a)(b)(1) Management. Previously cited 05/17/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 05/17/16. 28 Pa. Code 211.12(c) Nursing services. Previously cited 03/26/15. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 03/26/15, 05/17/16.

Based on resident group interview and staff interviews, it was determined that the facility failed to meet the voting interests and needs of residents by failing to provide adequate evidence that residents were orally informed and assisted with registering or obtaining absentee ballots for voting for three of eight nursing units (Eshelman Run; Lititz Run and Reed Run). Findings include: A resident group interview was completed with seven participants on May 13, 2016 at 10:00 a.m. The residents were asked how did they find out about their right to vote in the 2015 municipal and 2016 general primary elections; and if staff assisted with coordinating with both registering or application for absentee ballot. Residents D1; E5; I4 and N6 reported that none from the facility had talked to them about voting and consequently were not provided with an absentee ballot for either election. Interview with the Director of Social Service, Employee E3, on May 17, 2016 at 11:15 a.m., revealed that residents were informed of their right to vote secondary to their written resident handbook; and that the voting information was also posted on the facility in-house television channel. Facility documentation, provided by Employee E3, confirmed that information regarding the 2015 municipal election was posted for one day, August 24, 2015, on the resident in-house television channel. Employee E3 confirmed that it was unknown if residents had the opportunity to watch television specifically the in-house channel for these written postings. Employee E3 provided facility documentation that only six residents residing in facility during the 2015 and 2016 elections were assisted with registering or obtaining an absentee ballot. 28 Pa. Code: 201.29(a)(d)(i) Resident rights 28 Pa. Code: 211.12(d)(3) Nursing services Previously cited 3/26/2015 28 Pa. Code: 211.16(a) Social services

Based on review of facility policies and procedures related to staff treatment of [REDACTED]. Findings include: Review of facility policy and procedure entitled, Staff treatment of [REDACTED]. After the investigation had been completed a determination would be made as to the initial allegation of abuse. Procedure Step VII proceeded that following receipt of allegation of abuse, the State agency would be informed immediately via the electronic event reporting system by the Director of Nursing. Review of facility policy entitled, Resident Abuse, last updated February 26, 2013, indicated that facility prohibits abuse and mistreatment of [REDACTED]. Review of facility policy entitled, Resident Abuse Prevention, last updated February 26, 2013, provided for those components necessary to ensure that each resident was free from abuse, including identification and reporting/response. Policy further indicated that facility maintained a zero tolerance policy regarding abuse and mistreatment. Procedure Step IV proceeded for staff to document all bruises of unknown origin sustained by residents on a Resident Incident Report Form which would then be forwarded to the Director of Nursing or Administrator for determination if an investigation needed to be conducted. Procedure Step VII proceeded for reporting of the allegation of abuse immediately via the electronic event reporting system to the State agency and orally to the local Agency on Aging. Review of Resident F1's clinical record revealed that the resident was admitted to facility December 25, 2015. Review of the resident's 60 day assessment, dated February 16, 2016, assessed the resident as cognitively intact. Review of licensed nurse note, dated March 29, 2016, documented that at 7:15 p.m. the nurse aide reported to this nurse of bruises measuring; 4 centimeter(cm) by 6 cm; 4.5 cm by 5 cm and 2 cm by 1.5 cm purple bruise to left forearm and 5 cm by 7 cm purple bruise to top of left hand. The nurse documented that resident stated it happened during the shower on 7-3 shift today, March 29, 2016. and the registered nurse supervisor was notified. Subsequent nurse note, dated March 30, 2016 at 12:54 a.m., documented that this nurse was asked to assess resident for four new rather large bruises on left hand and forearm. Nurse documented that there was a 5 cm by 7 cm bruise on top of hand; a 4.5 cm by 5 cm above wrist; a 2 cm by 1.5 cm bruise on mid forearm and a 4 cm by 6 cm bruise on upper forearm. Nurse note documented that when Resident F1 was asked what occurred, resident stated, I don't know but it happened during my shower this morning. Resident was described to be one assist for transfers and care and did wear long sleeves. Review of facility documentation and interview by Director of Nursing with Resident F1, on March 30, 2016 at 2:00 p.m., indicated that when resident was asked about the bruises resident reiterated that it happened during the shower. Further dcoumentation revealed that Director of Nursing then inquired of resident if resident felt that caregiver was rough or abusive. Resident F1's statement to Director of Nursing, on March 30, 2016, was not signed or dated by the resident. A subsequent interview with Resident F1, documented on April 10, 2016, revealed that resident described the aide as rough and grabbed resident's arm when assisting resident into the shower. Facility documentation into this incident of alleged abuse resulting in bruises for Resident F1, revealed that a request by the Director of Nursing for management to speak with Employee E5 (alleged perpetrator), was not requested by the Director of Nursing until April 2, 2016, four days later. Review of facility documentation into this allegation of abuse incident, accompanied by Director of Nursing, on May 17, 2016 at 12:00 p.m., confirmed that facility failed to obtain from the alleged perpetrator, direct care Employee E5, a written/or oral statement until E5 returned to work on April 5, 2016, seven days later. Interview with Director of Nursing, on May 17, 2016 at 12:00, indicated that the facility did not do a thorough review into resident's bruises and ignored resident's allegation of staff being rough during care; further facility did not report this allegation of abuse timely through the State electronic event reporting system and by written report within five working days to the appropriate State survey agency. 483.13(c) Staff treatment of [REDACTED].>Pa Chapter 51: Code: 51.3(g)(6) Notification 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee 28 Pa. Code: 201.18(a)(b)(1) Management 28 Pa. Code: 201.29(a)(d) Resident rights 28 Pa. Code: 211.10(b)(c)(d) Resident care policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 3/26/2015 28 Pa. Code: 211.16(a) Social services

Based on observations, staff interview and review of facility policy, it was determined that the facility failed to serve food under sanitary conditions while serving lunch and dinner in one of nine dining areas observed (Lititz Run). Findings include: Review of facility policy entitled, Dress Code Policy for Community Life Coordinators and Homemakers, updated May 28, 2014, revealed that hair nets must be worn during food preparation and plating of food during meal times. An observation of the Lititz Run dining area, on May 12, 2016 at approximately 5:00 p.m., revealed a homemaker plating food for delivery to those residents of the Lititz Run dining room. The homemaker was not wearing a hair net during the time that the plating of food occurred. An subsequebt observation of the Lititz Run dining area, on May 13, 2016 at approximately 12:05 p.m., revealed the same homemaker plating food for delivery to those residents of the Lititz Run dining room and not wearing a hair net during the time that the plating of food occurred. Interview with Employee E4 on May 17, 2016 at approximately 1:30 p.m. confirmed that the homemakers should be wearing hair nets while plating food for residents during meal times. 28 Pa. Code 211.6(f) Dietary Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set assessment (MDS-periodic assessment of resident status and care needs) were completed accurately to reflect the residents status for nine of 24 residents (Residents A10, B5, B11, B13, C6, C11, C12, D11, and H14 ). Findings include: Review of Resident A10's current plan of care revealed that the resident wore orthotic shoes and a right ankle brace. Review of the quarterly assessment completed on March 20, 2015 Section O0500 Restorative Nursing Programs did not code the number of days that the resident used the brace. Further review of the assessment indicated that under Section G0300 Functional Limitation in Range of Motion identified the resident with impairments on both sides of the upper extremities. Interview with licensed nursing staff on March 26, 2015 at 1:42 p.m. confirmed that Section O0500 Restorative Nursing Programs should have coded the number of days the brace was use on the resident and that Section G0300 Functional Limitation in Range of Motion was erroneously coded. The resident only had limitation of one side of the upper extremities and not on both sides. Review of Resident B5 November 2014 physician's orders [REDACTED]. Review of the significant change assessment dated [DATE] Section J Health Conditions- J1400 Prognosis coded a 0 for the resident not having a condition or chronic disease that may result in a life expectancy of less than 6 months. Interview with licensed nursing, Employee E3 on March 27, 2015 at 1:30 p.m. confirmed that the assessment was erroneously coded and it should have coded a 1for yes the resident having a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of Resident B11 December 2014 physician's orders [REDACTED]. Review of resident's quarterly assessment completed on March 10, 2015 under Section H0100 Appliances did not code the use of an intermittent cauterization. Review of social service documentation dated December 22, 2015 noted that the resident was officially being followed by hospice services. Interview with licensed nursing staff, Employee E3 on March 26, 2015 at 1:30 p.m. confirmed that the quarterly assessment of March 10, 2015 failed to include the resident use of an indwelling catheter. Employee E3 also indicated that there was no significant change assessment completed after the initiation of hospice services for the resident. Review of Resident B13's electronic clinical record revealed that the resident was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the admission comprehensive assessment completed May 20, 2014 and the quarterly assessment completed February 4, 2015 revealed that neither of the above mentioned assessments coded the resident's [DIAGNOSES REDACTED]. Interview with licensed nursing staff Employee E3 on March 26, 2015 at 2:27 p.m. confirmed that the [DIAGNOSES REDACTED]. Review of Resident C6 ' s clinical medical record revealed an admission MDS (Minimum Data Set which is a periodic assessment of needs and functioning level that is completed on all residents) that was completed for February 25, 2015 which revealed that in the bathing Section G0120- was coded as an " 8 " that this activity did not occur during the 7 day look back period. Review of Resident C6 ' s clinical medical record revealed a 14 day MDS that was completed for March 4, 2015 and Section E1100-change in behavior was not coded with any entry. Interview with licensed nurse, Employee E3 on March 26, 2015 at 2:15 p.m. revealed that the " 8 " activity did not occur for bathing was incorrect, and bathing for the resident did occur during that time period. Employee E3 also confirmed that Section E1100 was not coded and should have been. Review of Resident C11 ' s clinical medical record revealed a 30 day MDS was completed for March 7, 2015 which revealed that in the bathing section it was coded as an " 8 " that this activity did not occur during the 7 day look back period. Also upon review of this MDS, it revealed that Section E1100-change in behavior was not coded with any entry. Interview with Employee E3 on March 26, 2015 at 2:15 p.m. that the " 8 " activity did not occur for bathing was incorrect, and bathing for the resident did occur during that time period. Employee E3 also confirmed that the Section E1100 was not coded and should have been. Review of Resident C12 ' s clinical medical record revealed that the resident was ordered by the physician on March 5, 2016 a Hospice evaluation to be completed on the resident for initiation of services. Review of the clinical medical record revealed that Hospice services were initiated on March 6, 2015. Review of Resident C12 ' s clinical medical record revealed a significant change MDS was completed for March 13, 2015 as required when a Resident is placed on Hospice services. Review of the MDS revealed that Section J1400-Prognosis was coded as " No " and Section O-Special Treatments, Procedures, and Programs was not coded that Hospice Care was being provided. Interview with the DON on March 25, 2015 at 10:00 a.m. confirmed that these sections were not completed accurately and should reveal that the resident was on Hospice Services. Review of Resident D11's clinical record revealed an annual MDS was completed on July 30, 2014 which revealed that under Section G0110 Activities of Daily Living that Resident D11's Transfer Status G0110-B was coded as total dependence with two person physical assistance and under Section G0300-B Balance During Walking was coded as an " 8 " that this activity did not occur during the 7 day look back period. Section G0600 Mobility Devices was coded for use of a walker and not coded for the use of a wheelchair. Further review of Resident D11's clinical record revealed the resident having a [DIAGNOSES REDACTED]. Resident D11's current care plan revealed the use of an electric wheelchair for mobility and mechanical lift for all transfers. Under Section H0300 Urinary Continence and H0400 Bowel Continence had Resident D11 coded as always being continent of bowel and bladder. Further review of Resident D11's clinical record revealed the resident having a [DIAGNOSES REDACTED]. Resident D11 was care planned since admission (July 27, 2007) for frequently being incontinent of bowel and bladder and had been placed on a toileting program which consisted of being offered toileting every 2 to 3 hours. Interview with the Nursing Home Administrator and Director of Nursing on March 26, 2015 at 12:35 p.m. confirmed that Resident D11 ' s annual MDS dated [DATE] had been inaccurately coded. Review of Resident H14 ' s clinical medical record revealed that a quarterly MDS was completed for April 3, 2014 and an annual comprehensive MDS was completed for January 1, 2015 and both MDS ' s had Section G0120 coded as an " 8 " that bathing did not occur on the resident. Interview with Employee E3 on March 26, 2015 at 2:15 p.m. confirmed that the coding of " 8 " for the bathing section was coded incorrectly and bathing did occur during the look back period on the resident. 28 Pa Code 211.5(f) Clinical Records 28 Pa Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 2/25/14

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide social service interventions to assist resident to attain their highest level of psychosocial and medical functioning and/or failed to coordinate initial medical related speciality services for four of 29 residents reviewed (Resident B11, C6, H17, and I9). Findings include: Review of Resident B11 electronic clinical record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of nursing documentation dated December 15, 2014 noted that there resident stated that she was ready to die and that she felt that no one spoke to her when she was at the table. The resident stated that she was existing not living. Review of social service documentation dated December 15, 2015 revealed that the social services had been contacted by the resident's daughter in regards to the recent transfer of the resident into the skilled unit at the facility. The resident's daughter was concern that the resident was struggling with the adjustment into this unit. The resident had been stating that she no longer wanted to live and believed that she was a nuisance to the nursing staff. On December 16, 2015 social services documented that during interview, Resident B11 admitted to having thoughts that she would be better off dead. Social services asked the nursing staff to contact the resident's physician regarding the comments made by the resident and that the social worker would follow up as needed. Review of December 2014 physician's orders revealed that the physician was made aware on December 16, 2014 of the resident making statements about wanting to die and was placed on focused observation. There were no physician orders. Review of the resident's plan of care revealed that on December 18, 2014 a plan of care was initiated regarding there resident making statements about death wishes and that she could be tearful at times. The interventions included for the social work to provide the resident with individual support as needed or as requested. Further review of social service documentation dated January 27, 2015 indicted that Resident B11 ' s daughter contacted the social worker with concerns regarding the resident care and that the resident was not receiving enough attention from staff during the day and the resident had communicated to her husband that "she is ignored". The social worker notified the nursing staff of the concern expressed by the resident's daughter and a meeting was scheduled between the social services, nursing and the resident's daughter. Review of nursing documentation dated February 4, 2015 noted that the staff reported increased anxiety and requested from the physician an order for [REDACTED]. Further review of social service documentation dated March 2, 2015 revealed that the resident admitted during interview of having thoughts that she would be better off dead and that the resident was currently receiving an antianxiety medication. Interview with Employee E4 on March 26, 2015 at 11:00 a.m. confirmed that social services informed nursing of the resident feelings regarding wanting to die and asked for the physician to be notified. Employee E4 was not able to provide evidence that individual support was provided to Resident B 11 by social services to address the resident adjustment into the nursing unit, anxiety over her declining health status and the resident ' s desire to die. Review of Resident C6 ' s clinical medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident C6 ' s clinical medical record revealed multiple progress notes mentioning the resident was displaying symptoms of depression and thoughts of wanting to be dead due to her recent health decline. Nursing and social service progress notes dated February 25, 2015, February 28, 2015, March 4, 2015, March 12, 2015-twice indicated these symptoms. physician progress notes [REDACTED]. Review of Resident C6 ' s care plan indicated the resident had depression with crying episodes and was started on an antidepressant but did not indicate or mention the resident having passive suicidal ideation or thoughts of wanting to be dead, or any interventions such as close observations, referral to psychologist for assistance, or any plan of care to assist the resident in her current psychological situation other than the addition of an antidepressant medication and to monitor for side effects. A physician order was noted on March 23, 2015 for a psychiatric evaluation which was completed on March 25, 2015 a month after stating her first thoughts of wanting to be dead and after initiating an antidepressant medication. Review of the social services progress notes did not reveal any ongoing support or intervention by social services to include increased monitoring for safety, increased visits from social services to help the resident adjust to new surroundings and health concerns. Review of Resident H17 ' s clinical medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident H17 ' s physician ' s orders revealed an order that was initiated by a the registered nurse stated: " Per Social Services resident scored a 4 for mood. Resident agreed to having thoughts she would be better off dead and thoughts of self- harm. Resident has dementia and it is understood she cannot answer these questions appropriately. Review of the physician ' s order dated December 12, 2014 initiated by a Registered Nurse to the attending physician stated, " Resident will benefit from Psychological services " , and attending physician replied, " Not yet, increase Risperdal to 0.125mg twice a day. " Review of Resident H17 ' s care plan revealed no indication that the resident made any statements in regard to self-harm, and what interventions should be initiated by staff and the interdisciplinary team in regard to these statements. Review of the Social Services progress notes do not indicate any follow up from social services in regard to the depression symptoms and the verbalization of thoughts of wanting to be dead. There was also no further mention to initiate a referral to pastoral or psychological services to assist with the residents increased aggression, depression or passive suicidal thoughts. Interview with Employee E4 on March 26, 2015 at 2:00p.m, did confirm that these resident situations did occur and that social services did notify the nursing department, which in turn notified the physician, but Employee E4 could not provide any further evidence that Resident C6 and H17 were provided with additional social service support to help with their current psychological issues. The facility social service personnel also help coordinate initial medically related speciality services such as eye, dental, podiatry, hearing, mobility equipement with the resident and responsible party and the service. Review of Resident I9's clinical medical record revealed an admitted [DATE]. Review of Resident's admission Minimum Data Set (MDS-periodic assessment of the resident ' s care needs and status) completed for June 1, 2014 revealed that at Section L Oral/Dental Status the D was checked-indicating "obvious or likely cavity or broken natural teeth". After requesting dental information in regard to the dental issue addressed on the MDS on Resident I9 from the DON on March 24, 2015, the surveyor was given an medical specialist authorization sheet that is utilized by the facility to document if the resident or the resident's POA (Power of Attorney-the individual that can make decisions for resident) consent to dental treatment by facility consultants. Resident I9 ' s POA signed the consent for dental care September 19, 2014, almost 4 months after the resident was admitted to the facility. Interview with the DON on March 26, 2015 at 10:00 a.m. confirmed that Resident I9 still had not seen a dentist for evaluation and routine care since admission May 8, 2014. 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.10(a) Resident care policies 28 Pa Code: 211.16(b) Social services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop plans of care to reflect the resident ' s psychological health concerns for 2 of 24 residents (Residents C6 and H17); and failed to list a the most important side effects to be aware of for anti -psychotic medications for 5 of 24 residents (Residents C12, H14, H17, I5 and I9) ; and failed to develop a comprehensive behavioral care plan for 1 of 24 residents reviewed (Resident C12). Findings include: Review of Resident C6 ' s clinical medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident C6 ' s clinical medical record revealed multiple progress notes mentioning the resident was displaying symptoms of depression and thoughts of wanting to be dead due to her recent health decline. Nursing and Social Service progress notes dated February 25, 2015, February 28, 2015, March 4, 2015, and March 12, 2015-twice indicated these symptoms. physician progress notes [REDACTED]. Review of Resident C6 ' s care plan indicated the resident had depression with crying episodes and was started on an antidepressant but did not indicate or mention the resident having passive suicidal ideation or thoughts of wanting to be dead, or any interventions such as close observations, referral to psychologist for assistance, or any plan of care to assist the resident in her current psychological situation other than the addition of an antidepressant and to monitor for side effects. Review of Resident H17 ' s clinical medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident H17 ' s physician's order [REDACTED]. Resident agreed to having thoughts she would be better off dead and thoughts of self- harm. Resident has dementia and it is understood she cannot answer these questions appropriately. Another physician's order [REDACTED]. Increase [MEDICATION NAME] to 0.125mg twice a day. " Review of Resident H17 ' s care plan revealed no indication that the resident made any statements in regard to self-harm, and what interventions should be initiated by staff and the interdisciplinary team in regard to these statements. According to the Psychiatry Weekly research abstract, " Antipsychotics Medications and the Elderly " , www.psychweekly.com/aspx/article/ArticleDetail.aspx?articleid=57 <http://www.psychweekly.com/aspx/article/ArticleDetail.aspx?articleid=57> , " As with many other types of medications, the antipsychotics should be used with greater caution in elderly patient than in younger individuals ... Elderly patients taking [MEDICATION NAME] (and other older antipsychotics have a greater incidence of tardive dyskinesia compared to younger patients taking the same medications or elderly taking patients newer atypical antipsychotics " . Antipsychotic medications can cause movement disorder side effects that are unique for this drug classification. Ongoing assessment and monitoring is important to the continual well -being of the residents who are taking these medications. Review of Resident C12, H14, H17, I5 and I9 ' s clinical medical record revealed that these residents are currently being treated with antipsychotic medication-[MEDICATION NAME], and [MEDICATION NAME] (psychiatric medications that are used to help alleviate certain targeted behavioral or mental health symptoms). Review of their care plans revealed no information in regard to monitoring the residents for the EPS side effects (Extrapyramidal symptoms-are drug induced movement disorder that include acute and long term symptoms, which can include stiffness/rigidity of muscles, tremors, tongue rolling, cog-wheeling of upper limbs, and gait issues)that are exclusive to this medication class. Review of Resident C12, H14, H17, I5 and I9 ' s care plan did not include the assessment and/or monitoring of these particular side effects. Review of Resident C12 ' s clinical medical record revealed that he was admitted to the facility on [DATE] after a lengthy stay at a local community hospital for [MEDICAL CONDITION] and urosepsis (infection of the body, starting in the urinary tract). The Resident was given [MEDICATION NAME] (antipsychotic medication) while in the hospital for the [MEDICAL CONDITION] symptoms and it was discontinued on the day of admission to the facility. The resident was having some residual [MEDICAL CONDITION] behaviors from February 25 to March 5, 2015 with some confusion, agitation, refusals of medications and activities of daily living so he was placed back onto [MEDICATION NAME] on March 5, 2015. Review of Resident C12 ' s care plan was an entry date of March 9, 2015 mentioning the resident takes [MEDICATION NAME], but there is no mention of the behavioral issues, such as agitation, treatment and medication refusals that the resident was displaying on the unit. Interview with the DON, NHA and Employee E4 on March 26, 2015 at 2:00 p.m. confirmed that the care plans did not contain any of this information. F279 483.20(d) (k) Develop comprehensive care plans Previously cited 2/25/14 28 Pa Code 211.5(f) Clinical Records 28 Pa Code 211.11(a) Resident Care Plan Previously cited: 2/25/14 28 Pa code 211.12(c)(d)(1)(5)Nursing Services Previously cited: 2/25/15

Based on review of clinical record and staff interview it was determined that the facility staff failed to coordinate specialized foot care services for one of 24 residents reviewed. (Resident D18). Findings include: Review of Resident D18's clinical record revealed that the resident had been seen by the podiatrist on June 18, 2014 who recommended a follow-up visit in two to three months. However, there was no documented evidence that a follow-up visit had been completed. Further review of the clinical record revealed that the last time Resident D18 was seen by the podiatrist was on June 18, 2014. Interview with a licensed nurse, Employee E5 on March 26, 2015 at approximately 2:00 p.m. confirmed that there was no documented evidence that Resident D18 had been seen by a podiatrist since June 18, 2014. 28 PA. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited: 2/25/15

Based on clinical record review, interviews with residents and staff the facility failed to provide appropriate care and follow physician orders [REDACTED]. (Residents M7, K3). Findings include: Review of Resident M7's quarterly assessment dated [DATE] related the resident had a cognitive status score of 14 indicating the resident was cognitively intact. The assessment related the resident was incontinent of bowel and bladder. Review of current physician's recapped orders dated February 21, 2013 revealed that the resident was ordered 8 ounces of warm water, by mouth, daily at 7:00 a.m. USE TAP WATER ONLY, for constipation. The order was initially written on June 8, 2012. Review of nursing notes dated August 2, 2012 at 5:00 am revealed " Resident has an order for [REDACTED]. Resident awakened and told that water was a little hot. Resident verbalized she understood. Several minutes later resident rang call bell and said I was sipping on water and spit it on my chest. CNA applied barrier cream and reported the incident to the charge nurse. The supervisor was contacted and the supervisor will be in to check. Nurses notes related the supervisor assessed the resident with a 2.5cm x 3 cm superficial layer of skin absent".At that time resident refused cool compresses." Interview with DON on February 28, 2013, at 4:50pm, confirmed that the CNA should not have applied PeriGuard Antimicrobial Protectant Barrier Cream to the burn site without first informing the licensed nurse of the incident. The DON further confirmed, at that time, that an assessment by a licensed professional should have been conducted and an order obtained by the licensed nurse from the physician before a treatment was administered. Review of physician progress notes [REDACTED]. burn -When the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn. The burn causes pain, redness, swelling, and blistering.). Interview with DON on March 1, 2013 at 2:30 p.m. confirmed that the water given to Resident M7 on August 2, 2012 came from a hot water urn and was not warm tap water, as per the physician's orders [REDACTED]. Review of the facility's food temperature check sheet for Reed nursing unit, dated August 2, 2012 at 7:20 a.m., revealed that the water temperature of the urn, on August 2, 2012, the morning Resident M7 suffered the second degree burn, was recorded at 150 degrees Fahrenheit. Pennsylvania state regulations relate that hot water at hot water outlets (tap water) should not exceed 110 degrees Fahrenheit. .Temperature testing at the facility by all four surveyors on February 27, 2012 revealed that hot tap water temperatures did not exceed 110 degrees Fahrenheit. Observation of the electronic monitoring system in the presence of maintenance employee E7 on March 4, 2013, at approximately 9:30 am revealed water temperatures were electronically controlled to maintain consistent tap water temperature delivery at 110 degrees Fahrenheit throughout the facility. An electronic display showed the temperature of the water being delivered to each unit on a continuous basis. Observation at this time revealed that none of the temperatures exceeded 110 degrees Fahrenheit for the water system. Interview with resident M7 on February 27, 2013 at 2:30 pm, revealed the resident sustained [REDACTED]. The resident pointed to the sternal area (center of the chest wall) to show where the resident had sustained the burn. Resident M7 described the chain of events in detail and reported that the resident was lying down in bed and was unaware that the cup of water the resident was given that morning was filled to the brim and exceptionally hot. The resident explained that she did not anticipate the water to be so hot and when the resident went to take a sip, it spilled onto their chest wall. The resident reiterated several times during the interview, that the burn was very painful. The facility failed to follow physician orders [REDACTED]. Review of Resident K3''s annual MDS assessment (assessment of care needs and status)dated January 15, 2013, revealed a [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. The assessment also revealed that the resident was severely cognitively impaired and required extensive assistance with dressing and hygiene and was totally dependent on staff for bathing. Review of Resident K3's physician orders [REDACTED]. Orders also included to apply compression stocking in the morning, directions at the bedside. Orders also included for staff to wash stocking daily at 8:00 p.m. in cold water and hang to dry. Interview with nursing Employee E6 on March 1, 2013 who revealed that the resident's compression stockings were missing and that a missing items report was available for perusal. Interview with nursing Employee E6 further revealed that the facility was responsible replacing the stockings and that the social work department was following up with ensuring their replacement. Review of missing items report, dated January 25, 2013, revealed that Resident K3's custom compression stockings had been missing for since January 18, 2013. Review of social work progress notes dated January 31, 2013, six days later, revealed that a care conference meeting took place on that date, and that the resident's daughter was in attendance. Further review of the social work progress notes revealed that the resident's daughter had agreed during the care conference meeting to follow up with the company that originally made the stockings to order. Social service documentation revealed that on February 14, 2013, two weeks later, the resident's daughter left a message for the social worker regarding the company to replace the stockings. There is no evidence that the facility attempted to contact the company to order the stocking until February 19, 2013 (five days later). Social service documentation revealed that on February 20, 2013, the company called to the facility and reported that they would be out to measure the resident for the stockings on February 26, 2013 (39 days since stockings were missing). Social serviced notes stated stocking ordered February 27, 2013 Interview with the administrator and director of nursing on March 4, 2013 at approximately 2:30 p.m. revealed the resident received the replacement stockings on March 4, 2013 (45 days from January 18, 2013 when the stockings were deemed missing. . The facility failed to provide the Resident K3 with replacement compressed stockings timely which were ordered for the resident by the physician for medical conditions. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(e)(1) Management 28 Pa. Code:211.10(d) Resident care policies 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/16/12, 3/24/11