Every finding on record at Village at Penn State, The

Based on clinical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions for fall prevention which resulted in actual harm of pelvic fracture for one of three residents reviewed for falls (Resident 4). Findings include: Review of facility policy titled Falls Risk Assessment System Guidelines, last reviewed without changes January 31, 2026, revealed all residents will be assessed for initial risk for falls using The Fall Risk Assessment. Residents that score a 15 or greater will be considered at risk for falls. A plan of care will be initiated to address the fall risk factors. This assessment will begin on admission and be completed within 24 hours. If a resident triggers a risk for falls, the resident will have further assessment for risk for falls utilizing the Care Area Assessment (CAA) guidelines and the plan of care will be enhanced if indicated, to further minimize the risk of falls. The policy indicated for residents at risk, the care plan will incorporate the following: bed exit alarms, call light within reach, keep room door open, encourage family assistance, provide diversion, offer toileting every two hours, assess for toileting program, environmental room review to reduce hazards, bed in low position, fall mat, signs in room to ring call bell for assistance, and bed bolsters. Clinical record review revealed the facility admitted Resident 4 on March 5, 2026. Resident 4's diagnosis list at the time of admission included Dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and repeated falls. Review of Resident 4's fall risk assessment dated [DATE], at 1:29 PM revealed staff assessed Resident 4 as having the following risk factors: one to two falls in the past three months, disoriented at all times, ambulatory, incontinent, poor vision, balance problem while walking, decreased muscular coordination and requires the use of an assistive device (cane). The resident's fall risk score was evaluated as a score of 21 (if the total score is 10 or greater, the resident should be considered at high risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan). Review of Resident 4's admission MDS (Minimum Data Set - assessment completed at periodic intervals of time to determine resident care needs) dated March 9, 2026, revealed facility staff assessed the resident as having a BIMS (brief interview of mental status assessment) score of four (indicating severe cognitive impairment), independent with sitting to standing, chair to bed transfers, toilet transfers, and walking using a cane/walker. Further review of the same MDS assessment revealed Resident 4 had no recent falls in the last month, or in the last two to six months, contrary to the resident's admitting diagnosis of repeated falls and the fall risk assessment identifying Resident 4 as having one to two falls in the past three months which was completed prior to the MDS assessment. Review of Resident 4's physical therapy documentation revealed a therapy Discharge summary dated [DATE], indicating Resident 4 was on therapy caseload due to her difficulty in walking, and muscle weakness. Further review of a physical therapy progress report from April 2, to April 15, 2026, revealed Resident 4 ambulated 10 feet with partial to moderate assistance, and 50 feet with two turns, and partial to moderate assistance. Nursing documentation dated April 16, 2026, at 12:12 PM revealed nursing staff heard Resident 4 calling out from her room. Upon entering room Resident 4 was observed on the floor. Resident 4 was wearing nonslip footwear, her call bell was not alerting, and her assistive device (cane) was approximately five to ten feet away from her. Documentation revealed that Resident 4 was last toileted at approximately 9:15 AM. When Resident 4 was assisted from the floor to a standing position, she complained of pain in her right hip and the back of her head. Resident 4 was placed on her wheelchair and brought to the nursing station. The physician's assistant assessed Resident 4 and recommended sending her to the hospital for further evaluation. Nursing documentation dated April 16, 2026, at 4:28 PM revealed Resident 4's daughter called and informed the nurse of the preliminary results of Resident 4's CAT scan (medical imaging technique that uses X-rays and computer technology to create detailed cross-sectional images of the body) of her right hip showed two displaced fractures of her pelvic rami (bone structures of the pubic bone). Nursing documentation dated April 17, 2026, at 12:26 AM revealed the facility received fax communication indicating Resident 4 was admitted to the hospital. Resident 4 remained in the hospital until April 21, 2026, for treatment of the pelvic fractures. Review of information dated and submitted on April 16, 2026, by the facility to Department of Health revealed Resident 4's was admitted to the facility due to her progressing dementia and walks in her room independently, noting the resident had a cane but would carry it more than using it. It also noted therapy worked with the resident using a walker, but the resident would not always use the walker when in her room. The report further revealed, plan of care being followed. Review of Resident 4's initial and comprehensive care plan failed to reveal the facility implemented a plan of care to address Resident 4's fall risk or identify interventions to aid in the prevention of falls until April 16, 2026, subsequent to Resident 4's fall with resulting fracture. Further review of Resident 4's clinical record revealed there was no evidence to indicate any fall interventions were implemented to reduce the risk of falls or falls with injury for Resident 4 until after the incident on April 16, 2026. Interview with the Director of Nursing on May 14, 2026, at 12:52 PM confirmed the above finding for Resident 4. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/DevicesPreviously cited 6/6/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: An observation in the facility's Atrium kitchen and supply room, and the main kitchen on May 12, 2026, at 9:20 AM revealed the following: The Atrium gas burners were observed with black, charred particulate matter that was cooked on to the metal grates. The metal control knobs on the Atrium stove were observed to have a large amount of dust, debris, and grease built up between the knobs. The Atrium oven was observed with black and charred debris throughout the base of the oven and on the oven door. The supply room ice machine was observed to have plastic lids, a small square bucket, a cup, and boxes of gloves behind ice machine on the floor. The supply room refrigerator contained a container of milk was bulging and leaking. And was noted to be frozen. The main kitchen walk-in freezer had an uncovered sheet cake sitting on a shelf. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 13, 2026, at 2:00 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 6/6/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1). Findings include: Review of Employee 1's (nurse aide) personnel record revealed that the facility hired her on April 17, 2023. Review of training records provided by the facility for Employee 1 dated April 2025, to April 2026, revealed that Employee 1 completed six hours and 25 minutes of in-service education. Interview with the Nursing Home Administrator on May 14, 2026, at 12:04 PM confirmed the above findings for Employee 1. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on clinical record review and staff interview it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of four residents reviewed for advanced directives concerns (Resident 3). Findings include: Clinical record review revealed the facility admitted Resident 3 on March 30, 2026. Review of Resident 3's active physician order dated March 20, 2026, revealed staff are to implement full treatment in the event of a medical emergency (Full Code, chest compressions and breathing assistance). A POLST (Physician Orders for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) form signed by Resident 3 on March 23, 2026, revealed Resident 3 wanted staff to implement DNR (Do Not Resuscitate, do not provide chest compressions or assist with breathing) directives in the event of a medical emergency. The above findings for Resident 3 were reviewed during a meeting with Nursing Home Administrator and the Director of Nursing, on May 13, 2026, at 2:00 PM. Interview with the Director of Nursing on May 14, 2026, at 10:44 AM confirmed the above findings for Resident 3 and indicted that the facility received a new physician order dated May 13, 2026 (after surveyor's questioning) noting DNR, with limited interventions. The facility failed to ensure that active physician orders incorporated Resident 3's wishes related to end-of-life care. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a cardiac pacemaker for two of 11 residents reviewed (Residents 28 and 33).Findings Include: Clinical record review for Resident 28 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart), sick sinus syndrome (a malfunctioning of the heart that impacts the heart's natural pacemaker node), and atrial fibrillation (an irregular heart rhythm). Medical provider documentation for Resident 28 dated April 8, 2026, at 10:29 AM also revealed a diagnosis list that included the presence of a cardiac pacemaker. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 28 dated March 18, 2026, revealed an active diagnosis of the presence of a cardiac pacemaker. Review of Resident 28's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, or any associated precautions. Documentation related to Resident 28's pacemaker was requested in a meeting with the Nursing Home Administrator and Director of Nursing on May 13, 2026, at 11:10 AM. An observation of Resident 28's room on May 14, 2026, at 8:54 AM revealed there was a transmittal device on the resident's dresser located next to the bed. A concurrent interview with Employee 3, licensed practical nurse, revealed that the device was utilized to transmit data from the resident's pacemaker that is remotely monitored. A follow-up review of Resident 28's care plan provided by the facility after discussion about the resident's pacemaker revealed that the resident is at risk for bleeding from falls related to anticoagulant (a medication used to help prolong or prevent the clotting of blood) use. An intervention dated May 13, 2026, noted monthly pacemaker check. The care plan did not address the transmittal device care. The additional information for Resident 28 was reviewed with the Nursing Home Administrator and Director of Nursing on May 14, 2026, at 11:30 AM. Clinical record review for Resident 33 revealed a diagnosis list that included the presence of a cardiac pacemaker, sick sinus syndrome, and atrial fibrillation. Medical provider documentation for Resident 33 dated April 22, 2026, at 10:13 AM revealed a pacemaker with recent replacement. The diagnoses list included the presence of a cardiac pacemaker. Xray documentation for Resident 33 dated April 12, 2026, revealed results that included, Left sided pacemaker noted. Review of Resident 33's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, or any associated precautions. The information for Resident 33's pacemaker was reviewed in a meeting with the Nursing Home Administrator on May 13, 2026, at 11:10 AM and May 14, 2026, at 11:30 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to provide a written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for two of two residents reviewed for hospitalizations (Residents 2, and 4); and failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer that included all the necessary contents for one of two residents reviewed for hospitalizations (Resident 2).Findings include: Clinical record review revealed that resident 2 was admitted to the hospital on [DATE]. Review of the facility form related to bed hold information and notification of transfers did not include the following information: Notification of the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing. A statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Interview on May 13, 2026, at 1:00 PM, with Employee 2, Social Services, revealed that there was no evidence of written notification given to the resident representative. Clinical record review revealed that Resident 4 was transferred to the hospital on April 16, 2026. Review of the transfer notice given to Resident 4 and emailed to Resident 4's family revealed it did not contain all the necessary components, including a statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Interview with Employee 2 (social services) on May 13, 2026, at 1:36 PM confirmed the above findings for Resident 4. The above information regarding the transfer and bed hold notifications for Residents 2 and 4 were reviewed with the Nursing Home Administrator and the Director of Nursing on May 14, 2026, at 11:15 AM. 28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code 201.29(a) Resident rights

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen, Atrium kitchen, and pantry. Findings include: Observation of the Atrium kitchen on June 3, 2025, at 9:30 AM revealed the following: Multiple sheet pans were observed stored and in use in the cooking area contained significant black buildup on the pans. A large plastic wrap holder on the production table was observed with dried liquid splatter, food crumbs, and dust on the exterior and interior of the holder. The flooring under the dish machine, cooler, and food cooking equipment contained dirt/debris buildup on the flooring and wall edges. A three-tier black cart located across from the dish machine with clean glasses and trays stored on it had dried spills, dried food, and debris on the shelves of the cart. An observation of the main kitchen on June 3, 2025, at 9:50 AM, which is utilized to store food and prepare some food items for the Atrium kitchen revealed the following: A significant buildup of dirt/debris was observed on the walk-in freezer floor. A speed-rack (a tall rolling cart that hold trays of food) was observed in the walk-in cooler with trays of food stored on it. The rack was soiled with a buildup of dried food, dried spills, dust, and debris on the cart frame and tray holders. The wall behind the handwashing sink outside the dry storage area was covered in brown splatter four feet up the wall. A tilt kettle and braising kettle (cooking equipment) were observed in the cooking area by the steamer, covered in thick dust build up, which extended to the side of the steamer. Employee 1, director of dining services, indicated the kettles were out of service and the facility was waiting for new equipment. The knobs and front of additional cooking equipment in the main kitchen area (flat top, grill, and stove) were also observed with significant dust and blackened/debris build up. An observation of the of the pantry storage area located on the first floor of the Atrium on June 3, 2025, at10:30 AM revealed a large amount of water/liquid pooled on the flooring in front of the ice machine, the remainder of the flooring contained debris and was sticky. Dirt/debris was observed under the equipment and along all wall edges. A small metal table holding a juice dispenser unit was observed with dried, orange-colored spills on the top of the table. The lower shelf of the table was dusty and sticky. A cardboard box sitting on the shelf labeled main light fix atrium was partially stuck to the shelf. A previously opened gallon can of paint was sitting on top of the box. Two upright freezers in the pantry contained the following items that had no date to indicate when they were placed there or when the needed to be used by: Four packs of cupcakes A bag of potato tots Two bags of onion rings Two pans of cream chipped beef Three pans of beef stew Six pans of meat lasagna The above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 4, 2025, at 2:15 PM. 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 7/19/24 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen, Atrium kitchen, and pantry.Findings include:Observation of the Atrium kitchen on June 3, 2025, at 9:30 AM revealed the following:Multiple sheet pans were observed stored and in use in the cooking area contained significant black buildup on the pans.A large plastic wrap holder on the production table was observed with dried liquid splatter, food crumbs, and dust on the exterior and interior of the holder.The flooring under the dish machine, cooler, and food cooking equipment contained dirt/debris buildup on the flooring and wall edges.A three-tier black cart located across from the dish machine with clean glasses and trays stored on it had dried spills, dried food, and debris on the shelves of the cart.An observation of the main kitchen on June 3, 2025, at 9:50 AM, which is utilized to store food and prepare some food items for the Atrium kitchen revealed the following:A significant buildup of dirt/debris was observed on the walk-in freezer floor.A speed-rack (a tall rolling cart that hold trays of food) was observed in the walk-in cooler with trays of food stored on it. The rack was soiled with a buildup of dried food, dried spills, dust, and debris on the cart frame and tray holders.The wall behind the handwashing sink outside the dry storage area was covered in brown splatter four feet up the wall.A tilt kettle and braising kettle (cooking equipment) were observed in the cooking area by the steamer, covered in thick dust build up, which extended to the side of the steamer. Employee 1, director of dining services, indicated the kettles were out of service and the facility was waiting for new equipment.The knobs and front of additional cooking equipment in the main kitchen area (flat top, grill, and stove) were also observed with significant dust and blackened/debris build up.An observation of the of the pantry storage area located on the first floor of the Atrium on June 3, 2025, at10:30 AM revealed a large amount of water/liquid pooled on the flooring in front of the ice machine, the remainder of the flooring contained debris and was sticky. Dirt/debris was observed under the equipment and along all wall edges.A small metal table holding a juice dispenser unit was observed with dried, orange-colored spills on the top of the table. The lower shelf of the table was dusty and sticky. A cardboard box sitting on the shelf labeled main light fix atrium was partially stuck to the shelf. A previously opened gallon can of paint was sitting on top of the box.Two upright freezers in the pantry contained the following items that had no date to indicate when they were placed there or when the needed to be used by:Four packs of cupcakesA bag of potato totsTwo bags of onion ringsTwo pans of cream chipped beefThree pans of beef stewSix pans of meat lasagnaThe above information was reviewed with the Nursing Home Administrator and Director of Nursing on June 4, 2025, at 2:15 PM.483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 7/19/2428 Pa. Code 201.14 (a) Responsibility of Licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for two of two residents reviewed (Residents 4 and 18). Findings include: Clinical record review for Resident 4 revealed current physician orders for Oxycodone HCI 5 milligrams (mg) Clinical record review for Resident 4 revealed current physician orders for Acetaminophen (a medication used to control mild pain) extra strength 500 mg by mouth every four hours as needed for pain, (no pain level identified), Oxycodone HCI (a narcotic pain medication used to control moderate to severe pain) oral tablets 5 mg every six hours as needed for moderate to severe pain, and Oxycodone HCI oral tablets 5 mg give 2.5 mg every four hours as needed for pain (no pain level identified). Review of Resident 4's most recent quarterly MDS (Minimum Data Set, an assessment completed by the facility, at intervals to determine the care needs of the resident) dated May 20, 2025, revealed that she had occasional pain with the worst pain being a 5 on a scale of 1-10, and that she received scheduled, and as needed pain medication during the assessment period. Review of Resident 4's medication administration record for May 2025, revealed that she did not receive her as needed Acetaminophen Extra Strength 500 mg during the month. Review of Resident 4's medication administration records (MAR) for May 2025, revealed that she received Oxycodone 2.5 mg as follows: May 6, 2025, 5:47 AM for a pain level of 6 May 11, 2025, at 9:15 PM for a pain level of 5 May 18, 2025, at 9:32 AM for a pain level of 7 Review of Resident 4's medication administration records (MAR) for May 2025, revealed that she received Oxycodone 5 mg as follows: May 2, 2025, at 10:00 AM for a pain level of 7 May 2, 2025, at 5:00 PM for a pain level of 7 May 14, 2025, at 4:28 PM for a pain level of 7 May 23, 2025, at 1:34 PM for a pain level of 8 May 24, 2025, at 12:47 PM for a pain level of 8 May 25, 2025, at 1:09 PM for a pain level of 3 May 28, 2025, at 10:27 AM for a pain level of 7 May 29, 2025, at 5:27 AM for a pain level of 6 May 30, 2025, at 6:41 AM for a pain level of 6 May 31, 2025, at 12:40 PM for a pain level of 6 Interview with the Director of Nursing on June 5, 2025, at 10:35 AM revealed that the facility does not have a policy defining mild, moderate, or severe pain. She also confirmed that Resident 4's current physician orders do not provide specific guidance to the administering nurse indicating what as needed pain medication should be administered in accordance with Resident 4's pain ratings. Interview with the Nursing Home Administrator and Director of Nursing on June 5, 2025, at 2:22 PM, confirmed the above noted findings related to Resident 4's pain. Clinical record review for Resident 18 revealed the resident was ordered Acetaminophen (a medication used to treat mild pain) Oral Tablet 325 mg two tablets every four hours as needed for pain on April 16, 2025. Resident 18 also had an active order for Tramadol HCL (a narcotic used to treat moderate to moderately severe pain) 50 mg every four hours as needed for pain ordered on April 16, 2025. A review of Resident 18's May and June 2025 medication administration records revealed the resident was administered the as needed Acetaminophen as follows: May 18, 2025, for a pain level of 6 May 20, 2025, for a pain level of 4 May 25, 2025, for a pain level of zero, and again for a pain level of 6 May 26, 2025, for a pain level of 5, again for a pain level of 6, and administered again for a pain level of 6 May 28, 2025, for a pain level of 6 Resident 18 had not been administered any as needed Acetaminophen to date in June 2025. A review of Resident 18's May and June 2025 medication administration records revealed Resident 18 was administered the Tramadol as follows: May 3, 2025, for a pain level of 8 May 14, 2025, for a pain level of 9 May 20, 2025, for a pain level of 5 May 21, 2025, for a pain level of 6 May 22, 2025, for a pain level of 6 May 25, 2025, for a pain level of 9 May 26, 2025, for a pain level of 6 June 4, 2025, for a pain level of 5 There was no evidence of any pain scale parameters for Resident 18's as needed pain medication of Acetaminophen and Tramadol to indicate which medication staff is to utilize for the resident's pain. The Nursing Home Administrator and Director of Nursing confirmed in an interview on June 5, 2025, at 2:30 PM that there was no pain parameters indicated as to what pain level staff should administered which medication. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for two of two residents reviewed (Residents 4 and 18).Findings include:Clinical record review for Resident 4 revealed current physician orders for Oxycodone HCI 5 milligrams (mg)Clinical record review for Resident 4 revealed current physician orders for Acetaminophen (a medication used to control mild pain) extra strength 500 mg by mouth every four hours as needed for pain, (no pain level identified), Oxycodone HCI (a narcotic pain medication used to control moderate to severe pain) oral tablets 5 mg every six hours as needed for moderate to severe pain, and Oxycodone HCI oral tablets 5 mg give 2.5 mg every four hours as needed for pain (no pain level identified).Review of Resident 4's most recent quarterly MDS (Minimum Data Set, an assessment completed by the facility, at intervals to determine the care needs of the resident) dated May 20, 2025, revealed that she had occasional pain with the worst pain being a 5 on a scale of 1-10, and that she received scheduled, and as needed pain medication during the assessment period.Review of Resident 4's medication administration record for May 2025, revealed that she did not receive her as needed Acetaminophen Extra Strength 500 mg during the month.Review of Resident 4's medication administration records (MAR) for May 2025, revealed that she received Oxycodone 2.5 mg as follows:May 6, 2025, 5:47 AM for a pain level of 6May 11, 2025, at 9:15 PM for a pain level of 5May 18, 2025, at 9:32 AM for a pain level of 7Review of Resident 4's medication administration records (MAR) for May 2025, revealed that she received Oxycodone 5 mg as follows:May 2, 2025, at 10:00 AM for a pain level of 7May 2, 2025, at 5:00 PM for a pain level of 7May 14, 2025, at 4:28 PM for a pain level of 7May 23, 2025, at 1:34 PM for a pain level of 8May 24, 2025, at 12:47 PM for a pain level of 8May 25, 2025, at 1:09 PM for a pain level of 3May 28, 2025, at 10:27 AM for a pain level of 7May 29, 2025, at 5:27 AM for a pain level of 6May 30, 2025, at 6:41 AM for a pain level of 6May 31, 2025, at 12:40 PM for a pain level of 6Interview with the Director of Nursing on June 5, 2025, at 10:35 AM revealed that the facility does not have a policy defining mild, moderate, or severe pain. She also confirmed that Resident 4's current physician orders do not provide specific guidance to the administering nurse indicating what as needed pain medication should be administered in accordance with Resident 4's pain ratings.Interview with the Nursing Home Administrator and Director of Nursing on June 5, 2025, at 2:22 PM, confirmed the above noted findings related to Resident 4's pain.Clinical record review for Resident 18 revealed the resident was ordered Acetaminophen (a medication used to treat mild pain) Oral Tablet 325 mg two tablets every four hours as needed for pain on April 16, 2025.Resident 18 also had an active order for Tramadol HCL (a narcotic used to treat moderate to moderately severe pain) 50 mg every four hours as needed for pain ordered on April 16, 2025.A review of Resident 18's May and June 2025 medication administration records revealed the resident was administered the as needed Acetaminophen as follows:May 18, 2025, for a pain level of 6May 20, 2025, for a pain level of 4May 25, 2025, for a pain level of zero, and again for a pain level of 6May 26, 2025, for a pain level of 5, again for a pain level of 6, and administered again for a pain level of 6May 28, 2025, for a pain level of 6Resident 18 had not been administered any as needed Acetaminophen to date in June 2025.A review of Resident 18's May and June 2025 medication administration records revealed Resident 18 was administered the Tramadol as follows:May 3, 2025, for a pain level of 8May 14, 2025, for a pain level of 9May 20, 2025, for a pain level of 5May 21, 2025, for a pain level of 6May 22, 2025, for a pain level of 6May 25, 2025, for a pain level of 9May 26, 2025, for a pain level of 6June 4, 2025, for a pain level of 5There was no evidence of any pain scale parameters for Resident 18's as needed pain medication of Acetaminophen and Tramadol to indicate which medication staff is to utilize for the resident's pain.The Nursing Home Administrator and Director of Nursing confirmed in an interview on June 5, 2025, at 2:30 PM that there was no pain parameters indicated as to what pain level staff should administered which medication.28 Pa Code 211.10(c) Resident care policies28 Pa Code 211.12(d)(1) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to implement interventions related to fall injury prevention for one of four residents reviewed (Resident 31) and failed to provide adequate supervision resulting in a fall for one of four residents reviewed (Resident 23). Findings include: Clinical record review for Resident 31 revealed a diagnosis list that included a history of falling. Resident 31's quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 9, 2025, revealed that staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 5, which indicated severe cognitive impairment. Review of Resident 31's care plan revealed that the resident is at risk for falls due to unsteady gait and poor balance. An intervention dated December 17, 2024, instructed staff to have dycem (a material used to prevent slipping or sliding) on the seat of the resident's wheelchair and the top of the pressure alarm to prevent sliding. Clinical documentation for Resident 31 revealed an Incident Note dated May 18, 2025, at 10:35 PM that indicated the resident had fallen out of the wheelchair and sustained a skin tear to the left elbow. The note indicated, Dycem was not on resident's pressure alarm per care plan, new piece applied. Facility documentation revealed an incident report with a staff statement dated May 19, 2025, that revealed the staff member was sitting at the nursing station and saw Resident 31 scooting to the edge of his wheelchair. The resident leaned to the left and fell out of the wheelchair. An interview with the Nursing Home Administrator on June 6, 2025, at 12:30 PM revealed that the facility could provide no further documentation on the lack of the care planned intervention for Resident 31's wheelchair. Clinical record review for Resident 23 revealed a progress note dated January 3, 2025, at 5:55 PM that indicated Resident 23 had a fall at 5:10 PM. The note indicated she was walking with her walker down the hallway on the first floor accompanied by a nurse aide. The nurse aide heard a gasp and then noted that the resident started to fall sideways and hit the right side of her head on the bottom of the door that leads up to second floor. Resident 23 lost consciousness for a few seconds but became aware and talking with staff. The facility called 911 at 5:15 PM and Resident 23 was taken to the hospital. A progress note dated January 3, 2025, at 10:20 PM revealed that Resident 23 returned from the hospital with a small bump on her right temple. She had no new orders related to the fall. Clinical record review for Resident 23 revealed a fall risk evaluation dated December 21, 2024, that indicated Resident 23 had a fall risk score of 20. The evaluation indicated that any score over 10 is a fall risk. The fall risk evaluation revealed that Resident 23 had 3 or more falls in the past 3 months, intermittent confusion, she is ambulatory, incontinent, she had a decrease in muscular coordination, and required the use of an assistive device. The evaluation section for clinical suggestions revealed no suggestions. Further clinical record review into Resident 23 revealed a physical therapy evaluation dated December 19, 2024, that indicated the reason for the referral was that Resident 23's daughter requested she be assessed due to her having lower extremity weakness, decreased balance, and gait abnormality. Medical factors on the evaluation indicated Resident 23 was a fall risk. The assessment summary indicated that the resident presented with strength impairments, decreased safety awareness, postural alignment/control, decreased functional capacity, and decreased balance. The evaluation indicated that Resident 23 required skilled physical therapy services to minimize falls, improve dynamic balance, increase lower extremity range of motion and strength, and promote safety awareness. The summary also indicated that Resident 23 refused physical therapy after the evaluation. Further review of therapy documentation revealed that Resident 23 was started on physical therapy on December 23, 2024. Review of physical therapy documentation for December 23, 2024, revealed that she required supervision or touching assistance with ambulation to walk 10 feet, and her baseline for transfers and ambulation were supervision to contact guard assistance with a rollator walker (a walker with wheels) 120 feet. A physical therapy progress note dated December 30, 2024, revealed that resident ambulated 350 feet with a rollator and stand by assistance. She had a slow cadence (a slow pace of steps taken per minute) with frequent stopping due to distractions. She had a forward posture with verbal cues throughout to stand tall and pick up her feet. A physical therapy progress note dated December 31, 2024, revealed that resident ambulated 700 feet with a rollator walker and stand by assistance. She had a shuffle and required verbal cues throughout to stand tall and stay close to her rollator walker. Review of Resident 23's task documentation for December 18, 2024, to December 31, 2024, revealed that her ambulation in the hallway ranged from independent to extensive assist of one person with her rollator walker. Review of Resident 23's care plan entitled Activities of Daily living self-care deficit initiated on July 11, 2023, revealed that she had no interventions indicating what type of ambulation assistance she needed. Review of Resident 23's care plan entitled At risk for falls related to gait/balance disturbances, last revised on May 20, 2025, revealed no interventions that indicated the resident's ambulation assistance needs, and there were no resolved care plan interventions that indicated what level of assistance she required with her ambulation. Review of the facility's investigation into Resident 23's January 3, 2025, fall revealed that the nurse aide was walking ahead of Resident 23, heard a gasp, turned around, and saw her fall. The facility failed to ensure that Resident 23 was provided with adequate supervision and appropriate fall interventions after it was noted that she had a fall risk assessment score of 20 on December 21, 2024, had declined in her balance and strength, and required verbal cues to safely ambulate as noted by physical therapy progress notes referenced above. Interview of Director of Nursing and Nursing Home Administrator on June 6, 2025, at 11:30 AM confirmed the above noted findings related to Resident 23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to implement interventions related to fall injury prevention for one of four residents reviewed (Resident 31) and failed to provide adequate supervision resulting in a fall for one of four residents reviewed (Resident 23).Findings include:Clinical record review for Resident 31 revealed a diagnosis list that included a history of falling.Resident 31's quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 9, 2025, revealed that staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 5, which indicated severe cognitive impairment.Review of Resident 31's care plan revealed that the resident is at risk for falls due to unsteady gait and poor balance. An intervention dated December 17, 2024, instructed staff to have dycem (a material used to prevent slipping or sliding) on the seat of the resident's wheelchair and the top of the pressure alarm to prevent sliding.Clinical documentation for Resident 31 revealed an Incident Note dated May 18, 2025, at 10:35 PM that indicated the resident had fallen out of the wheelchair and sustained a skin tear to the left elbow. The note indicated, Dycem was not on resident's pressure alarm per care plan, new piece applied.Facility documentation revealed an incident report with a staff statement dated May 19, 2025, that revealed the staff member was sitting at the nursing station and saw Resident 31 scooting to the edge of his wheelchair. The resident leaned to the left and fell out of the wheelchair.An interview with the Nursing Home Administrator on June 6, 2025, at 12:30 PM revealed that the facility could provide no further documentation on the lack of the care planned intervention for Resident 31's wheelchair.Clinical record review for Resident 23 revealed a progress note dated January 3, 2025, at 5:55 PM that indicated Resident 23 had a fall at 5:10 PM. The note indicated she was walking with her walker down the hallway on the first floor accompanied by a nurse aide. The nurse aide heard a gasp and then noted that the resident started to fall sideways and hit the right side of her head on the bottom of the door that leads up to second floor. Resident 23 lost consciousness for a few seconds but became aware and talking with staff. The facility called 911 at 5:15 PM and Resident 23 was taken to the hospital.A progress note dated January 3, 2025, at 10:20 PM revealed that Resident 23 returned from the hospital with a small bump on her right temple. She had no new orders related to the fall.Clinical record review for Resident 23 revealed a fall risk evaluation dated December 21, 2024, that indicated Resident 23 had a fall risk score of 20. The evaluation indicated that any score over 10 is a fall risk. The fall risk evaluation revealed that Resident 23 had 3 or more falls in the past 3 months, intermittent confusion, she is ambulatory, incontinent, she had a decrease in muscular coordination, and required the use of an assistive device. The evaluation section for clinical suggestions revealed no suggestions.Further clinical record review into Resident 23 revealed a physical therapy evaluation dated December 19, 2024, that indicated the reason for the referral was that Resident 23's daughter requested she be assessed due to her having lower extremity weakness, decreased balance, and gait abnormality. Medical factors on the evaluation indicated Resident 23 was a fall risk. The assessment summary indicated that the resident presented with strength impairments, decreased safety awareness, postural alignment/control, decreased functional capacity, and decreased balance. The evaluation indicated that Resident 23 required skilled physical therapy services to minimize falls, improve dynamic balance, increase lower extremity range of motion and strength, and promote safety awareness. The summary also indicated that Resident 23 refused physical therapy after the evaluation.Further review of therapy documentation revealed that Resident 23 was started on physical therapy on December 23, 2024. Review of physical therapy documentation for December 23, 2024, revealed that she required supervision or touching assistance with ambulation to walk 10 feet, and her baseline for transfers and ambulation were supervision to contact guard assistance with a rollator walker (a walker with wheels) 120 feet.A physical therapy progress note dated December 30, 2024, revealed that resident ambulated 350 feet with a rollator and stand by assistance. She had a slow cadence (a slow pace of steps taken per minute) with frequent stopping due to distractions. She had a forward posture with verbal cues throughout to stand tall and pick up her feet.A physical therapy progress note dated December 31, 2024, revealed that resident ambulated 700 feet with a rollator walker and stand by assistance. She had a shuffle and required verbal cues throughout to stand tall and stay close to her rollator walker.Review of Resident 23's task documentation for December 18, 2024, to December 31, 2024, revealed that her ambulation in the hallway ranged from independent to extensive assist of one person with her rollator walker.Review of Resident 23's care plan entitled Activities of Daily living self-care deficit initiated on July 11, 2023, revealed that she had no interventions indicating what type of ambulation assistance she needed.Review of Resident 23's care plan entitled At risk for falls related to gait/balance disturbances, last revised on May 20, 2025, revealed no interventions that indicated the resident's ambulation assistance needs, and there were no resolved care plan interventions that indicated what level of assistance she required with her ambulation.Review of the facility's investigation into Resident 23's January 3, 2025, fall revealed that the nurse aide was walking ahead of Resident 23, heard a gasp, turned around, and saw her fall.The facility failed to ensure that Resident 23 was provided with adequate supervision and appropriate fall interventions after it was noted that she had a fall risk assessment score of 20 on December 21, 2024, had declined in her balance and strength, and required verbal cues to safely ambulate as noted by physical therapy progress notes referenced above.Interview of Director of Nursing and Nursing Home Administrator on June 6, 2025, at 11:30 AM confirmed the above noted findings related to Resident 23.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that the facility determined a resident's ability to self-administer medications for one of one resident reviewed (Resident 14). Findings include: Observation of Resident 14 on June 4, 2025, at 12:35 PM revealed she was sitting in her chair beside her bed with her bedside table in front of her. On the bedside table she had Flonase nasal spray (a steroid medication used to treat various signs and symptoms that could be caused by allergies) and Afrin nasal spray (a medication used to treat nasal congestion and stuffiness). She indicated that she brought them to the facility from the hospital. She said that both medications have been on her windowsill or overbed table since she came to the facility on [DATE]. She also indicated that she does self-administer the medications. Clinical record review for Resident 14 revealed no physician's order that the resident may self-administer the medication, or that the facility determined the resident was able to safely self-administer the medication. The surveyor confirmed the above noted information related to Resident 14 self-administering medications with the Nursing Home Administrator and Director of Nursing on June 5, 2025, at 10:30 AM. 8 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9 (a)(1)(b) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that the facility determined a resident's ability to self-administer medications for one of one resident reviewed (Resident 14). Findings include: Observation of Resident 14 on June 4, 2025, at 12:35 PM revealed she was sitting in her chair beside her bed with her bedside table in front of her. On the bedside table she had Flonase nasal spray (a steroid medication used to treat various signs and symptoms that could be caused by allergies) and Afrin nasal spray (a medication used to treat nasal congestion and stuffiness). She indicated that she brought them to the facility from the hospital. She said that both medications have been on her windowsill or overbed table since she came to the facility on May 21, 2025. She also indicated that she does self-administer the medications. Clinical record review for Resident 14 revealed no physician's order that the resident may self-administer the medication, or that the facility determined the resident was able to safely self-administer the medication. The surveyor confirmed the above noted information related to Resident 14 self-administering medications with the Nursing Home Administrator and Director of Nursing on June 5, 2025, at 10:30 AM. 8 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9 (a)(1)(b) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain a safe and sanitary environment in the main kitchen and smaller kitchen area located on the skilled nursing unit. Findings included: Initial tour of the facility's main kitchen on [DATE], between 11:10 AM and 11:40 AM with Employee 1, Director of Dining, revealed the following: Observation of the walk-in freezer off the hallway revealed: A package of veggie burgers was undated, and the package was open exposing them to the ambient air. Several packages of what Employee 1 identified as ground pork sausage were undated. An undated bag of breadsticks was open to the ambient air. Observation of the walk-in cooler off the hallway revealed: A package of onions had an expired use-by date of ,d+[DATE]. Four bags of celery had no dates on them. A container labeled plain halibut had an expired use-by date of ,d+[DATE]. There were eight foil wrapped items in a tray that Employee 1 identified as potatoes with no labels or dates on them. There were multiple packaged avocado halves in a box with an expiration date of [DATE]. Two operating fans on the condenser unit located in the interior of the cooler revealed a significant accumulation of dust. Observation of the area that surrounded the main dumpsters to the main kitchen included two medical gloves (one black and one purple) on the ground, three discarded Styrofoam cups/bowls, a significant accumulation of dead leaves, and multiple paper/plastic items discarded behind the recycling dumpster. Observation of the walk-in cooler in the main kitchen revealed a partially filled gallon milk container with a sell by date of [DATE], and a container of lemon juice with an expiration date of [DATE]. The main kitchen had a significant accumulation of dust on a ceiling vent and adjacent ceiling tile above a food prep area. The protective coverings on two of the ceiling lights were partially ajar. There was a damaged corner of the wall at the floor between the kitchen and the dishwashing area. A concurrent interview with Employee 1 revealed that maintenance is aware of the issue. Employee 1 further noted that water from the dishwashing area leaks through the damaged wall area and puddles on the floor in the main kitchen area. Observation of the smaller kitchen located on the skilled nursing unit between 11:40 AM and 11:50 AM revealed the following: A floor drain near the food prep area contained various debris. Observation of Employee 5, dish washer, revealed the employee was observed in the kitchen area. Employee 5 had a full beard but did not have a beard guard covering the facial hair. A concurrent interview with Employee 1 revealed that the facility does not require Employee 5 to wear a hair restraining device over his beard. An operating air conditioning unit had an extensive build-up of a black colored substance on the vents of the unit. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 12:08 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to prevent abuse for one of one resident reviewed (Resident 8). Findings include: Clinical record review for Resident 8 revealed that on May 9, 2024, at 10:30 PM a nurse aide noted her to be sitting on the floor on the left side of her bed. The resident indicated that she slid out of bed. Concurrently, Employee 2, Registered Nurse, was made aware that Resident 8 fell out of bed, and the need to assess her for injuries. Review of the facility investigation into the fall revealed that Resident 8 did not have any injuries from the fall but there were concerns documented by Employee 3, nurse aide and Employee 4, Licensed Practical Nurse, that indicated they reported to the Director of Nursing (DON) that when Employee 2 came to assess Resident 8, she was verbally inappropriate to her. The investigation also confirmed that Resident 8 was interviewed and that the nurse was rude and unprofessional. Review of a witness statement from Employee 4, dated May 9, 2024, revealed that she notified Employee 2, that Resident 8 slid out of bed and was on the floor and she needed her to come and assess her. Employee 2 was trying to roll Resident 8 on to her side to assess her for injuries and rolled her into the door jamb bumping her right leg very hard . Resident 8 yelled and said it hurt. Employee 2 then yelled at Resident 8 and said, if you are not going to roll, I will mark you as a refusal. I am not hurting my back. Employee 2 rolled Resident 8 again and rolled her against the door jamb very roughly and she yelled again and looked at Employee 3 and said, I hate her. Review of a statement from Employee 3 dated May 9, 2024, revealed that when Employee 2 came into the room to examine Resident 8, she seemed very annoyed and spoke in a very rude manner. She indicated that Employee 2 never told Resident 8 that she was going to roll her over, she just tried to flip her over causing her right shin bone to crack off the bathroom door jam. She stated that Employee 2 then proceeded to tell Resident 8 that if she was not going to roll, she would mark her as a refusal. Employee 2 then proceeded to try to roll her again causing her right leg to crack off the door jamb again. Review of Employee 2's statement dated May 10, 2024, related to this event revealed that she tried to turn Resident 8 to check her back side and right hip, which she said hurt but she kept resisting being turned. Every time she would try to turn Resident 8, she would push back. She indicated that she had an actively dying resident receiving frequent sedation and no licensed practical nurse on duty, so she was passing medications too. She also indicated in her statement that she had been very busy preparing for a long-distance move and was entering the final three days of her nearly 2-month notice. She then stated that she believed this incident was related to stress and frustration due to all these events together and that she was sorry and never meant any harm or disrespect. Review of the Director of Nursing's (DON) summary of the event revealed that on May 10, 2024, at 8:30 AM she interviewed Resident 8 who indicated that she slipped out of bed and called for help. Resident 8 indicated that they came and got her up and that another nurse came and was very angry with her for falling out of bed and yelled at her. She said the nurse told her that she broke the rules that were laid out for her and that she was not to go to the bathroom by herself. Resident 8 then indicated that the nurse threw her against the wall. When Resident 8 was assessed, there were no apparent injuries. Interview with the DON and Nursing Home Administrator on July 18, 2024, at 12:05 PM revealed that they unsubstantiated the allegation of abuse because Employee 8 did not intend to cause harm. They also indicated that they were going to educate her on recognizing stress and actions to take, but Employee 2 did not return to the facility after the investigation, and that they did not educate other staff responsible for the care of residents related to stress prevention and abuse. The facility failed to substantiate verbal and physical abuse related to Resident 8 and failed to educate all staff related to stress management and abuse prevention as it related to this event, to prevent reoccurrence. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to monitor for the effectiveness or adverse consequences of psychotropic medication use for one of five residents reviewed (Resident 8). Findings include: Clinical record review for Resident 8 revealed a current physician's order for Zoloft (a medication used to treat depression) 25 milligrams (mg) one time a day. Review of Resident 8's current care plan revealed a care plan focus area for depression related to dementia. The goal was for Resident 8 to remain free of signs and symptoms of depression, anxiety, or sad mood. The interventions indicated to monitor for side effects and effectiveness of the medication. Further clinical record review revealed no documented evidence that Resident 8 was being monitored for side effects or effectiveness of the medication. Interview with the Director of Nursing and Nursing Home Administrator on July 18, 2024, at 12:15 PM confirmed the above noted findings that there was no documented evidence that they were monitoring Resident 8 for side effects or effectiveness related to her antidepressant medication Zoloft. The facility failed to ensure proper monitoring of psychotropic medication use for Resident 8. 483.45(d)(e)(1)-(2) Drug Regimen is Free From Unnecessary Drugs Previously cited deficiency 10/5/2023 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions in response to falls for one of nine residents reviewed for falls (Resident 18); and ensure an environment free from potential accident hazards on one of two nursing units (first floor, Resident 28). Findings include: Clinical record review for Resident 18 revealed a nursing progress note dated March 25, 2023, at 4:40 AM that indicated she was found on the floor in the bathroom with her head partially in the shower. She had right lower back pain and two small open areas. She got up to use the bathroom and slipped. Her blood sugar was 51. A new intervention was to have Resident 18 ring her call bell for help and to provide a protein snack at bedtime. Review of the facility investigation into Resident 18's fall from March 25, 2023, at 4:40 AM revealed an incident review form dated March 29, 2023, that indicated that the potential contributing factor to the fall was that her blood sugar dropped. The new intervention would be to have the resident ring for help before getting out of bed and to eat a protein snack at bedtime. Review of Resident 18's task sheet (where daily care is recorded in the computer documentation system) revealed that the protein snack was never initiated until April 24, 2023. Review of Resident 18's nutritional services progress notes date April 18, 2023, revealed to provide increased protein snack options at bedtime. Interview with the Director of Nursing on August 11, 2023, at 11:18 AM revealed that there was no evidence that Resident 18's increased protein snacks were initiated until April 24, 2023. The facility failed to initiate a timely intervention in response to Resident 18's fall on March 25, 2023. Observation of Resident 28 on August 8, 2023, at 11:50 AM revealed she was wandering on the nursing unit. At 12:15 PM she exited the unit into the lobby. She indicated she was going to the dining room. Clinical record review for Resident 28 revealed a quarterly MDS (minimum data set, an assessment completed by the facility at intervals to determine care needs of the resident) assessment that revealed her BIMS (Brief interview for mental status) score was 3, indicating she has a severe cognitive impairment. Observation of the main lobby on August 9, 2023, at 4:03 PM revealed that one of the double doors that led to the first-floor nursing unit was propped open creating unfettered access from the nursing unit to the main lobby. The automated glass doors from the main lobby and another unlocked and unmonitored door led from the main lobby to the parking lot. No staff were present in the nursing unit hallway or facility main lobby on the date and time of the observation. Interview with Employee 9 (registered dietitian who was in an office within the main lobby) on August 9, 2023, at 4:04 PM revealed that she was unaware of the unsecured doors. During the interview with Employee 9 while observing the unsecured doors, Employee 1 (health care associate/main lobby receptionist) arrived in the lobby area and confirmed that she left the main lobby area unattended to perform another task on the first floor. The unsecured and unmonitored doors presented a potential accident hazard for a wandering resident. The surveyor reviewed the above door security concerns with the Nursing Home Administrator and the Director of Nursing on August 10, 2023, at 2:00 PM. The Nursing Home Administrator confirmed that doors between the nursing unit and the main lobby should always closed and secured via a keypad. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for three of five residents reviewed (Residents 14, 21, and 22). Findings include: Clinical record review for Resident 14 revealed a current care plan for staff to provide restorative active ROM (range of motion, movement of the body to maintain a resident's ability) to her bilateral upper extremities (arms, BUE) to maintain functional performance and active ROM to her bilateral lower extremities (legs, BLE) to increase strength to improve functional mobility. Review of task documentation for Resident 14 from June and July 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: Active ROM to BUE: June 8, 13, 14, 17, 18, and 27, 2023 July 5, 6, 7, 11, 20, and 25, 2023 Active ROM to BLE: July 7, 2023 Clinical record review for Resident 21 revealed a current care plan for staff to provide a restorative transfer program for strengthening and passive ROM to her 3rd and 4th digits of her left hand and BUE. Review of task documentation for Resident 21 from June, July, and August 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: Transfer program: June 3, 11, 14, 16, 22, 23, and 27, 2023 July 11, 15, 18, 21, and 24, 2023 August 3, 4, and 10, 2023 Clinical record review for Resident 22 revealed an Occupational therapy referral dated May 6, 2023, for staff to provide restorative passive ROM to her BUE for 2 sets x 10 BID (twice daily) Review of task documentation for Resident 22 from May, June, July, and August 2023, revealed that staff documented not applicable or did not document completion of the restorative task on the following dates: May 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30 and 31, 2023 June 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 22, 23, 24, 25, 26, 27, 28, and 30, 2023 July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 30, 2023 August 2, 4, 7, 8, and 10, 2023 The surveyor reviewed the above information on August 9, 2023, at 2:45 PM with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents' responsible parties for three of five residents reviewed for hospitalization concerns (Residents 2, 18, and 20). Findings include: The facility policy entitled, Bed Hold Policy, last reviewed without changes on November 15, 2022, revealed that before transferring a resident to the hospital, the facility would provide the resident and responsible party (or family) a copy of the facility's bed hold policy and rates. The facility would hold a resident's bed placement at that designated rate as long as the resident and/or family member/responsible party authorized payment. The procedures portion of the policy indicated that the facility would type in the specific bed-hold policy and rates in that reserved section; however, there were no specific entries made by the facility specific to their rates. Clinical record review for Resident 2 revealed nursing documentation dated August 2, 2023, at 3:45 AM that nurse aide staff found Resident 2 laying on the floor in his room. Resident 2 had slurred and stuttered speech. Resident 2 was not oriented to person or time, had constricted pupils, and staff called emergency medical services to transport Resident 2 to the hospital. Staff notified Resident 2's son of the transfer by telephone. Medication administration documentation dated August 2, 2023, at 9:05 AM revealed that Resident 2 was admitted to the hospital. The facility provided a letter dated August 2, 2023, addressed to Resident 2's nickname (without his legal full name or mention of his responsible party) that noted his transfer to the hospital was necessary to evaluate any possible injuries after his fall. The notice indicated that the facility would hold Resident 2's bed during his hospitalization if payment was arranged. The notice indicated that if Resident 2's stay was covered by the continuing care community contract, the bed-hold fees were included in the monthly fee. The facility did not provide any documentation to indicate that Resident 2's responsible party received written notification of the facility's bed-hold policy at the time of transfer of Resident 2's transfer and admission to the hospital on August 2, 2023. Interview with the Director of Nursing and the Nursing Home Administrator on August 11, 2023, at 11:00 AM confirmed that the facility did not have evidence that Resident 2's responsible party received the notice of the facility's bed-hold policy. Clinical record review for Resident 18 revealed a progress note dated April 10, 2023, at 4:41 AM that indicated she was found on the floor in the bathroom in a pool of blood. She was sent out to the hospital related to being on a blood thinner. The facility did not provide any documentation to indicate that Resident18's responsible party received written notification of the facility's bed-hold policy at the time of Resident 18's transfer and admission to the hospital on April 10, 2023. Clinical record review for Resident 20 revealed that the facility transferred him to the hospital on July 29, 2023, related to issues with his foley catheter. The surveyor requested that the facility provide evidence that Resident 2, 18, and 20's responsible party received written notification of the facility's bed-hold policy during an interview with the Nursing Home Administrator and the Director of Nursing on August 9, 2023, at 2:00 PM. The facility did not provide any documentation to indicate that Resident 20's responsible party received written notification of the facility's bed-hold policy at the time of his transfer to the hospital on July 29, 2023. Interview with the Director of Nursing on August 11, 2023, at 12:45 PM confirmed that the facility did not have evidence that Resident 18 or Resident 20's responsible party received written notification of the facility bed-hold policy at the time they were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a)(1) Resident rights