Amoroso Healthcare And Rehabilitation Woodridge

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled' Policy Services Overview, revised April 2019, reads, in part, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy continued, Pharmacy services are available to residents 24 hours a day, seven days a week. Also, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner. Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and muscle weakness, with an admission date to the facility on February 25, 2026. Review of Resident 2's Medication Administration Record (MAR), dated February 1 through 28, 2026, revealed the following medication order: Amlodipine Besylate give 5 mg by mouth one time a day related to essential hypertension (primary). Review of the MAR revealed that on February 26, 2026, the medication was not administered by the nursing staff as ordered by Resident 2's physician. Additional review of Resident 2's MAR revealed the following medication order: Valsartan-Hydrochlorothiazide oral tablet 320-25 MG, Give 1 tablet by mouth one time a day related to essential hypertension (primary). Review of the MAR revealed that on February 26, 2026, the medication was not administered by the nursing staff as ordered by Resident 2's physician. Review of Resident 2's progress notes, dated February 26, 2026, regarding those medications not administered, read Awaiting delivery. RN [Registered Nurse] Supervisor, RP [Resident Representative], and provider aware. An interview with the Director of Nursing on March 11, 2026, at 11:28 AM, revealed an acknowledgment that those medications ordered for Resident 2 were not available from the contracted pharmacy. The interview also revealed that the facility has contracted pharmacy services with another provider to prevent medication shortages for its residents. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on policy review, document review, and staff interview, it was determined that the facility failed to ensure that the services provided met professional standards of quality for two of four resident records reviewed (Residents 1 and 4).Findings Include: Review of the facility's policy, titled Administering Medications, revised April 2019, read, Medications are administered in a safe and timely manner, as prescribed. The policy continued, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive, incurable, but treatable inflammatory lung disease causing obstructed airflow) and hypotension (abnormally low blood pressure). Review of Resident 4's clinical record revealed diagnoses that included respiratory failure (a critical condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide) and atrial fibrillation (a common heart condition characterized by an irregular, often rapid heart rate). Review of the facility's incident report dated March 1, 2026, read, as follows: [Resident 1] told this nurse that on evening shift Sunday, the LPN [licensed practical nurse/Employee 4] brought in medications for both her and her roommate [Resident 4], put them down on the bedside tables, and left. The report continued, [Resident 1's] roommate [Resident 4] noticed a pink and white pill in there she did not take, she said 'these are not mine' [Resident 1] stated 'I take a pink and white pill' they called the nurse [Employee 4] in who realized she gave them the wrong medications. An interview with the Director of Nursing on March 11, 2026, at 11:22 AM, revealed she was made aware of the medication error on the next day and confirmed Residents 1 and 4 did not take each other's medications. The interview also revealed that Employee 4 was an agency-contracted nurse and will not be returning to the facility for employment. 28 Pa. Code 201.18 (b) (1) Management28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner that enhances his or her quality of life for one of four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled Dignity, dated 2001, read, Residents are treated with dignity and respect at all times. Also, Resident goals, choices, preferences, values, and beliefs, are respected and honored.This begins at initial admission and continues throughout the resident's stay. Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed an admission date to the facility on February 25, 2026. Review of a documented statement, dictated to the Director of Nursing, dated February 26, 2026, revealed that upon admission to the facility, Resident 2 was provided with a bedpan for use with toileting with assistance by staff and Resident 2's daughter. Review of the facility's Grievance/Concern form, completed by Resident 2's daughter, read the Nurse Aide (Employee 3), Encouraged Resident 2 to 'pee' in her brief and they will change her. The Grievance/Concern continued that Employee 3 put a pamper on her [Resident 2]. Review of a document titled Employee Progress Discipline Notification, dated February 26, 2026, revealed that Employee 3 was assigned to provide care to Resident 2, including toileting, and was subsequently suspended for three days for double briefing Resident 2 instead of offering the bedpan or assistance with ambulating to the restroom. An interview with the Director of Nursing on March 11, 2026, at 12:23 PM, confirmed Employee 3 was suspended and ultimately terminated from her position at the facility related to the care provided to Resident 2. 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice and the comprehensive plan of care for one of four residents reviewed (Resident 2).Findings Include: Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed a recent hospitalization resulting in surgery to the spine. According to documentation, Resident 2's wound/incision required staples, and the care to the site should be open to air. Review of a document titled Employee Progress Discipline Notification, dated February 26, 2026, revealed that the Nurse Aide (Employee 3) assigned to provide care to Resident 2 was suspended for three days for double briefing Resident 2 with the knowledge that the surgical site needed to be open to air. An interview with the Director of Nursing on March 11, 2026, at 12:23 PM, confirmed Employee 3 was suspended and ultimately terminated from her position at the facility related to the care provided to Resident 2, and confirmed Resident 2 should not have been provided with briefs covering the surgical site. 28 Pa. Code 201.18 (b) (1) Management28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for two of 19 residents reviewed (Residents 4 and 85). Findings include: Review of facility policy, titled Weighing and Measuring a Resident last reviewed May 21, 2025, read, in part, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Review the resident's care plan to assess for any special needs of the resident. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed the following orders: Glucerna with Carb Steady 1.5 calories 300 milliliters via feeding tube every six hours, dated September 8, 2025; a consistent carbohydrate diet with a pureed texture and thin liquids; may have pleasure foods per hospice, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's physician order history revealed that she had an order for monthly weights until September 11, 2025. Review of Resident 4's weight documentation revealed that no weight was documented in January 2025, February 2025, April 2025, May 2025, or July 2025. Further review of Resident 4's documented weights revealed that on March 11, 2025, she weighed 225 pounds; June 1, 2025, she weighed 201 pounds; August 5, 2025, she weighed 200 pounds; and September 1, 2025, she weighed 192.4 pounds. Review of Resident 4's clinical record revealed that she had no nutritional assessments completed by the facility dietician between December 11, 2024, and September 8, 2025. Review of Resident 4's clinical record failed to reveal any documentation that Resident 4's physician, hospice provider or family were notified of her 24 pound weight loss in June 2025. Review of Resident 4's hospice nurse's visit note dated June 4, 2025, revealed that she was tolerating tube feedings and refusing to be fed orally. Pt is spitting food out. The note failed to include any documentation about the 24-pound weight loss. Review or Resident 4's hospice nurse's visit note dated June 13, 2025, revealed that she was tolerating tube feedings, but failed to include any documentation of the 24-pound weight loss. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated June 18, 2025, revealed that the hospice physician documented Resident 4 was receiving Glucerna 1.5 calories 250 milliliters every six hours via her feeding tube with 120 milliliter water flushes before after feedings; that she was allowed comfort feedings with pureed diet and nectar thick liquids as tolerated. The note failed to include any notation of Resident 4's 24-pound weight loss but did include that Resident 4 no longer responds to her daughter or takes anything by mouth from her. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated July 16, 2025, the hospice physician again documented the use of tube feeding for Resident 4 but failed to include any documentation of her weight loss. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated August 13, 2025, the physician again documented the use of a tube feeding for Resident 4 and indicated that she no longer takes anything by mouth but failed to include any documentation of her weight loss. Review of Resident 4's progress notes revealed a note by the dietician dated September 8, 2025, at 5:57 PM, that indicated she was evaluating Resident 4 for a new onset of a pressure injury and that she was triggering for desirable significant weight loss of 32-33lb (-14.5%) over six months. The note further indicated that she had recommended changes to Resident 4's tube feeding amount, water flushes, and added vitamins to promote wound healing. During a staff interview with the Director of Nursing (DON) on October 1, 2025, at 1:30 PM, she indicated that the facility dietician does not complete nutritional assessments on residents receiving hospice services. She said that this would be deferred to hospice since she was under their services. She further indicated that the facility does not typically weigh people on hospice. During a final interview with the Nursing Home Administrator (NHA) and DON on October 21, 2025, at 1:14 PM, the DON indicated that Resident 4 was a unique case given she is under hospice services, but receiving tube feedings and remaining a full code. She confirmed that staff should have been weighing her monthly since that was the physician's order. The DON further confirmed that Resident 4's physician, hospice provider, and Representative should have been notified of the weight loss in June 2025 when it was noted to have occurred to have possibly prevented further weight loss. She confirmed that there was no documentation to support that Resident 4's provider, hospice provider, or the dietician had been made aware of Resident 4's weight loss or made in changes in her treatment regimen until September 8, 2025. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. During an interview with Resident 85 on September 29, 2025, at 10:59 AM, he revealed he has been losing weight at the facility because he sometimes receives food he can't eat and doesn't get food per his preference. Review of Resident 85's care plan revealed a focus area that read, in part, The resident has [a] potential nutritional problem related to food allergies/sensitivities with an intervention for Obtain weight as ordered. Notify Medical Doctor, Registered Dietitian of any significant changes for further review, with a start date of September 11, 2025. Review of Resident 85's physician orders revealed an order for Weigh daily times 3 then weekly times 4 then monthly, every day shift every Sunday for 4 weeks, with a start date of September 9, 2025. Review of Resident 85's clinical record revealed he had a weight measure obtained on September 14, 2025, and not again until September 28, 2025. Review of Resident 85's weight change from September 14 to 28, 2025, revealed he had experienced a 5.1% significant weight loss from 138.8 pounds to 131.6 pounds. Review of Resident 85's clinical record revealed the facility obtained another weight measure on October 1, 2025, that was back up to 139.2 pounds. During an interview with the DON on October 1, 2025, at 10:34 AM, she revealed the facility weight policy indicated weight is usually measured upon admission and monthly during the resident's stay, but since current professional standards of practice recommend residents should be weighed weekly for the first 4 weeks after admission it should be updated. She further revealed since the Resident had a physician order for weekly weights at that time, it should have been followed. The DON also stated that staff had obtained a reweigh measure in response to the weight measure on September 28, 2025, due to it likely being a discrepancy, but she would expect reweigh weight measures to be completed within 24 hours. 28 Pa Code 201.18(b)(1) Management28 Pa. Code 211.10(c)Resident care policies28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for two out of 19 residents reviewed (Residents 4 and 83).Findings include: Review of the facility policy, titled Falls - Clinical Protocol, with a last revised date of March 2018, and a last reviewed date of May 21, 2025, revealed, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's clinical record progress notes revealed that she had a fall from her bed on September 20, 2025. Review of Resident 4's clinical record progress note dated September 20, 2025, at 9:55 AM, that revealed that the facility had contacted Resident 4's hospice provider about providing Resident 4 with a different bed that could be positioned lower to the floor since the one that they had already provided could be positioned in this manner. In addition, a progress note dated September 20, 2025, at 10:29 AM, indicated that the facility had contacted Resident 4's Representative to update her on the incident. The note further indicated that Resident 4's Representative requested that Resident 4 be provided with a second body pillow and that fall mats be placed on the floor for safety. Review of Resident 4's care plan revealed a care plan focus for potential for falls with interventions that included, but were not limited to, body pillow to left and right side when in bed, dated September 20, 2025; keep bed in lowest position, dated July 26, 2024; and fall mats to bilateral sides of bed requested by [representative], dated September 20, 2025. Observation of Resident 4 on September 29, 2025, at 1:30 PM, revealed that she was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. Subsequent observations on September 30, 2025, at 10:00 AM and 12:25 PM; and on October 1, 2025, at 8:55 AM, all revealed the same findings: the Resident was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. During a staff interview on October 1, 2025, at 11:07 AM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), observations and care plan findings were shared by the surveyor. The NHA indicated that the fall mats were not placed because the interdisciplinary team had reviewed the request by Resident 4's Representative and decided against them and, therefore, the fall mats should not have been care planned. When observation of the bed height of approximately two feet in the lowest position was discussed, the DON indicated that they were awaiting a different bed from hospice and that hospice had provided her current bed. During a staff interview with Employee 5 (Nurse Aide) on October 1, 2025, at 11:45 AM, she demonstrated that the bed was as low as it could go. She indicated that she had told administrative staff about it several times. Observation of Resident 4 on October 1, 2025, at 12:35 PM, revealed that the bilateral fall mats had been placed on both sides of her bed. Observation of Resident 4 on October 21, 2025, at 9:00 AM, revealed she was in bed with bilateral body pillows in place, her bed was approximately two feet off the floor, and the bilateral fall mats were present at both sides of her bed. During a final staff interview with the NHA and DON on October 21, 2025, at 11:17, the NHA again indicated that, although the interdisciplinary team had decided against the fall mats, staff went ahead and implemented them since they were care planned. The NHA confirmed that since they were care-planned, they should have been in place since September 20, 2025. He also confirmed that Resident 4's lowest bed height was still approximately two feet from the floor and that the falls mats could help prevent injuries should Resident 4 fall from bed again. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed a fall risk care plan with an intervention for Resident 83 to have a fall mat to the right side of the bed, initiated on February 7, 2025, and revised on February 8, 2025; and an intervention to keep bed in lowest position, initiated on February 14, 2024. Review of a fall incident report on Resident 83 that occurred on July 3, 2025, revealed the Resident had an unwitnessed fall in their room and was found lying on the right side of the bed, without injury. Further review of the incident report revealed Resident 83's bed was not in a low position at the time of the fall and their fall mat was not present. Observation of Resident 83 on September 30, 2025, at 1:55 PM, revealed the Resident was lying in bed with no fall mat present on the floor and their bed was not in the lowest position. Interview conducted with the NHA on October 21, 2025, at 11:05 AM, revealed they would have expected Resident 83's interventions to have been in place. 28 Pa. Code 201.18(b)(1)(2) Management28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 19 residents reviewed (Residents 18 and 83).Findings include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting with a last revised date of April 2025, and a last reviewed date of May 21, 2025, revealed 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care including appropriate support and assistance with: mobility (transfer and ambulation). Review of Resident 18's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hypertension (high blood pressure). Review of Resident 18's comprehensive care plan revealed an ADL care plan with an intervention that Resident 18 requires total lift and 2-staff participation with transfers, with an initiation date of March 6, 2023, and a revision date of June 30, 2025. Another intervention included in Resident 18's ADL care plan includes that they prefer to be out of bed in their chair after they are changed, initiated on March 22, 2023, and revised on July 26, 2024. Further review of Resident 18's care plan revealed a focus area that there is a potential risk of adjustment due to resident age is younger than general population, with an initiation date of March 7, 2023, and a revision date of April 20, 2023; and an intervention that Resident 18 would like to arise at 7:00 AM and be put back to bed at approximately 9:30 PM - 10:00 PM. Interview conducted with Resident 18 on September 29, 2025, at 10:00 AM, the Resident revealed that the Resident was waiting to get up out of bed. Interview conducted with Employee 4 on September 29, 2025, at 10:02 AM, revealed that Resident 18 is hard to understand and that the Resident was waiting to get up. Observations of Resident 18 on September 29, 2025, at 10:20 AM, 11:14 AM, and 11:40 AM, revealed Resident 18 was still lying in bed waiting to get up. Observation at 11:47 AM revealed two staff members went into Resident 18's room with a lift to get them up out of bed. During an interview with the Nursing Home Administrator (NHA) on October 21, 2024, at 11:05 AM, he revealed he would have expected Resident 18's care plan to have been followed. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed an ADL care plan with an intervention that the Resident required total lift and 2-staff participation with transfers, initiated on February 14, 2024, and revised on July 26, 2024. Further review of Resident 83's care plan revealed a care plan for dialysis and an intervention that after Resident 83 returns from dialysis, to offer them rest period in bed (Resident request to be laid down after she gets back from dialysis), initiated on August 15, 2025. Observation conducted on September 30, 2025, at 1:04 PM, revealed Resident 83's call light was on. Interview conducted with Resident 83 on September 30, 2025, at 1:17 PM, revealed that she wanted to get put back in bed and has been back from dialysis since 11:00 AM, and does not feel well. Observation conducted on September 30, 2025, at 1:22 PM, revealed a staff member going into Resident 83's room and turning the call bell off and exiting the room. Interview conducted with Resident 83 on September 30, 2025, at 1:24 PM, revealed that the staff member told Resident 83 they will get someone to assist putting Resident 83 into bed. Observation on September 30, 2025, at 1:52 PM, revealed two staff members going into Resident 83's room with a lift to assist them into bed. During an interview with the NHA on October 1, 2025, at 10:52 AM, they revealed that they would expect Resident 18's plan of care to have been followed, and for Resident 83 to have been put back into bed upon returning from dialysis. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident condition for six of 19 residents reviewed (Residents 2, 4, 5, 7, 15, and 32).Findings include: Review of Resident 2's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 4 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (persistent high blood pressure), and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 2's Annual MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 18, 2025, revealed under Section M- Skin Conditions, Resident 2 was marked no to indicate he was not at risk of a pressure ulcer. During an interview with the Director of Nursing (DON) on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed orders for a consistent carbohydrate diet with a pureed texture and thin liquids, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's Quarterly MDS with the assessment reference date of March 26, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Modified Quarterly MDS with the assessment reference date of June 26, 2025, revealed in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Quarterly MDS with the assessment reference date of September 24, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. During a staff interview with the Nursing Home Administrator (NHA) and DON on October 1, 2025, at 11:29 AM, the DON confirmed that Resident 4's aforementioned assessments were coded inaccurately and that modifications would be completed. Review of Resident 5's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and chronic respiratory failure (respiratory disease that results in decreased ability of the lungs to either oxygenate the blood or remove carbon dioxide from the blood). Review of Resident 5's physician orders revealed an order for olanzapine (atypical antipsychotic medication used to treat mental health conditions) 5 milligrams twice a day, which was active since January 29, 2025. Review of Resident 5's Quarterly MDS with an assessment reference date of May 4, 2025, revealed Section N - Medications was coded to reflect Resident 5 was not receiving an antipsychotic medication; however, review of Resident 5's medication administration record revealed that at the time of the Quarterly MDS, Resident 5 had been receiving the antipsychotic medication. During a staff interview on October 21, 2025, at approximately 1:10 PM, the DON confirmed that Resident 5's Quarterly MDS with assessment reference date of May 4, 2025, should have been coded to reflect Resident 5's use of an antipsychotic medication. Review of Resident 7's clinical record revealed diagnoses that included gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), feeding difficulties, and abnormal posture. Review of Resident 7's Quarterly MDS with ARD of August 4, 2025, revealed under Section K- Swallowing/Nutritional Status was marked yes to indicate he had received intravenous (IV) fluids during the look back period for the assessment. Review of Resident 7's clinical record failed to reveal notation that they received IV fluids during the lookback. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 15's clinical record revealed diagnoses that included acute and chronic respiratory failure with hypoxia (conditions where the lungs cannot adequately exchange gases leading to low oxygen levels and potentially high carbon dioxide levels) and encounter for palliative care (specialized medical care aimed at enhancing the quality of life for patients with serious illnesses). Review of Resident 15's clinical record revealed she was admitted to hospice care (medical care for people who are expected to live six months or less, and focus on comfort and quality of life) on July 13, 2024, with an admitting diagnosis of chronic respiratory failure and hypoxia. Review of Resident 15's Quarterly MDS with ARD of July 19, 2025, revealed under Section I- Active Diagnoses, subsection I6300. Respiratory failure, it was marked no to indicate she did not have that active diagnosis. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 32's clinical record revealed diagnoses that included type II diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin) and chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Residents 32's Annual MDS with an ARD of April 7, 2025, and Quarterly MDS's with assessment reference dates of July 28, 2025, and September 23, 2025, revealed that Resident 32 was coded in Section N. Medications that he had received one insulin injection in all the aforementioned assessment periods. Review of Resident 32's clinical record physician orders and Medication Administration Records for April 2025, July 2025, and September 2025, failed to reveal that Resident 32 was ordered or received any insulin injections during the assessment periods. During a staff interview with the NHA and DON on October 1, 2025, at 11:20 AM, the DON indicated that Resident 32 had received Ozempic injections during the assessment periods and that it was coded inaccurately as insulin on Resident 32's aforementioned assessments. She further indicated that assessment modifications would be completed. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 9).Findings include: Review of facility policy, titled Psychotropic Medication Use, with a last review date of May 21, 2025, revealed, in part, Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. 2. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include: a. admission or readmission; c. an irregularity identified during the drug regimen review. Behavioral and Other Non-Pharmacological Interventions: 1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support gradual dose reduction. Informed consent: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representatives right to accept or decline treatment. Dose, Duration, and Duplicate Therapy: 3. Duplicate therapy (use of two or more medications of the same pharmacological class or category .) is generally not indicated unless there is a documented clinical rationale for the use of multiple medications from the same class or with similar effects. 5. Medications prescribed by a specialist or began in another care setting, such as the hospital, must be clinically indicated and documented in the resident's medical record. Review of facility policy, titled Medication Regimen Reviews, with a last review date of May 21, 2025, revealed, in part, Timeframe for Reporting: 3. The consultant pharmacist provides the director of nursing and medical director with a written, signed, dated copy of all medication regimen reports. 4. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. Physician Response: 1. Upon receiving the MRR [Medication Regimen Review] report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. 2. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. Review of Resident 9's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 9's current physician orders revealed orders for duloxetine (a medication used to treat depression) 60 milligrams one capsule daily, dated June 19, 2025; mirtazapine (a medication used to treat depression)15 milligrams one tablet at bedtime, dated June 19, 2025; sertraline (a medication used to treat depression) 150 milligrams daily, dated June 19, 2025; quetiapine (a medication used to treat psychotic disorders) 100 milligrams administer one and a half tablets at bedtime, dated June 19, 2025; quetiapine 25 milligrams administer one tablet one time daily, dated September 5, 2025; and consult psychiatry to evaluate and treat as needed, dated August 21, 2025. Review of Resident 9's clinical record failed to reveal any documentation that education was provided to Resident 9 or her Representative regarding the risk versus benefit of the ordered antipsychotic and antidepressant medications or that consent was obtained to administer the medications. Review of Resident 9's clinical record failed to reveal any documentation of Resident 9's identified target behaviors, any behavior monitoring for the use of the antipsychotic medication, or any side effect monitoring of the antipsychotic medication. Review of Resident 9's care plan failed to reveal any identified target behaviors. Review of Resident 9's clinical record revealed that the facility consultant pharmacist issued a recommendation to Resident 9's physician on July 15, 2025, which indicated, in part, Black box warning .Residents with dementia-related psychosis treated with atypical antipsychotics are at an increased risk of death .increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis .Please evaluate current therapy and indicate below the appropriate option for this resident. The form failed to reveal any physician documentation or review signature. Review of Resident 9's clinical record revealed an initial psychiatry consult note dated September 4, 2025, which indicated that Resident 9 had no supporting diagnosis for the quetiapine and that a gradual dose reduction would be initiated. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on October 1, 2025, at 11:15 AM, the DON indicated that Resident 9 was admitted to the facility on all the psychotropic medications. She said that the practitioner at the facility was not comfortable adjusting any of Resident 9's medications because of her long-term use of the medications. The DON indicated that the practitioner wanted psychiatric services to evaluate Resident 9 regarding the July 2025 recommendation and to assume management of Resident 9's psychotropic medications. The DON said that she could not answer as to why the practitioner did not consult psychiatric services until August 21, 2025, instead of in July 2025 when the pharmacist had made the recommendation to review the antipsychotic medication. Review of Resident 9's progress notes revealed that she was seen by her practitioner at the facility on July 18, 22, and 28, 2025; and August 14, 2025, and, although documentation included the medications Resident 9 was taking and her mood status at the time of the visit, the documentation failed to include any documentation regarding consulting psychiatry services to manage her psychotropic medications. Further review of Resident 9's progress notes revealed a note by her practitioner dated August 19, 2025, which indicated that a psych consult has been placed for recommendations. During a staff interview with the NHA and the DON on October 1, 2025, at 1:25 PM, the DON indicated that Resident 9 was admitted to the facility on all her psychotropic medications so the facility would not have obtained any consents. During a final staff interview with the NHA and the DON on October 21, 2025, at 11:22 AM, both confirmed that Resident 9's target behaviors should have been identified, and care planned and that behavior monitoring and side effect monitoring should have been in place. The DON confirmed that this should have been done at time of Resident 9's admission to the facility in June 2025. The DON confirmed that the pharmacy recommendation from July 15, 2025, was not addressed until September 4, 2025, when the psychiatry finally saw the Resident and began reducing the antipsychotic medication dose because Resident 9 was noted to have no supporting diagnosis for its use. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 19 residents observed (Resident 74).Findings include: Review of the facility policy titled, Answering the Call Light with last revised date of September 2022, and a last reviewed date of May 21, 2025, revealed 4. Be sure that the call light is plugged in and functioning at all times. Review of Resident 74's clinical record revealed diagnosis including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing). Review of Resident 74's comprehensive care plan reveals an ADL (Activities of daily living) care plan with an intervention for the Resident's call bell to be within reach, initiated on July 9, 2018. Observation conducted on September 30, 2025, at 12:30 PM, revealed Resident 74 was lying in bed with no call bell attached to their room or accessible to the Resident. Further observations conducted at 1:06 PM and 1:36 PM revealed Resident 74 still did not have a call bell attached or accessible to them in their room. Interview conducted with Employee 4 on September 30, 2025, at 1:51 PM, revealed that they were not sure why Resident 74 did not have a call bell, and further inspecting revealed the cord broke off. Employee 4 revealed that no one put a ticket for maintenance to look at it in their system and then left the room and returned at 1:54 PM with a new cord and plugged it in to ensure it worked. During an interview with the Nursing Home Administrator on October 1, 2025, at 11:05 AM, he revealed that he would have expected Resident 74 to have had a call bell attached to his room and accessible for the Resident to use and was unable to determine how long it was not functioning. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three pantry areas.Findings include: Review of facility policy, titled Policy: Storage Areas last reviewed May 21, 2025, read, in part, All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All freezer units are always kept clean and in good working condition. Review of facility policy, titled Food from Outside Sources last reviewed May 21, 2025, read, in part, Visitors/family member will label food and beverages with the resident's name, room number, and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility.Observation of the dry storage area on September 29, 2025, at 9:27 AM, revealed one bag of spiral pasta open without an open date, and one bag of elbow pasta open without an open date. Interview with Employee 2 (Cook) on September 29, 2025, at 9:28 AM, revealed bags of pasta should be labeled with an open date once opened. Observation of the reach-in freezer 1 in the main kitchen on September 29, 2025, at 9:31 AM, revealed two bags of steak fries with one open and both not dated; one package of hot dogs not dated with a heavy presence of ice crystals; and one package of sausages not dated with a heavy presence of ice crystals. Observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:33 AM, revealed one bag of sausage patties open and not dated. Further observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:34 AM, revealed the bottom of the freezer was heavily soiled with food debris. Interview with Employee 2 on September 29, 2025, at 9:35 AM, revealed she was not aware of a formal cleaning schedule for kitchen equipment, but it is the expectation that kitchen equipment is kept clean at all times. Observation in the Unit 2 Pantry Refrigerator on September 29, 2025, at 9:39 AM, revealed two bags of food from outside sources not labeled with resident names or dates. Observation in the Unit 2 Pantry Freezer on September 29, 2025, at 9:40 AM, revealed one ice cream container spilled over without a lid; two frozen beverages from outside sources without resident names or dates; and one frozen meal from an outside source with an expiration date of August 25, 2025. Observation of the April 2025 Unit 2 Refrigerator/Freezer Temperature Log revealed the refrigerator temperature failed to be recorded on April 5. Observation in the Unit 1 Pantry Refrigerator on September 29, 2025, at 9:43 AM, revealed cream of wheat in a Styrofoam cup without a date; a bag of food labeled with a resident's name, dated August 4 that appeared rotten; and a container of wilted salad, labeled with a resident's name, not dated, with a four odor. Observation of the September 2025 Unit 1 Refrigerator/Freezer Temperature Log on September 29, 2025, at 9:44 AM, revealed temperatures failed to be recorded on September 13, 21-23; and temperatures were already filled for September 30. Observation of the August 2025 Unit 1 Refrigerator/Freezer Temperature Log revealed temperatures failed to be recorded on August 5 for the refrigerator and August 19 for both the refrigerator and the freezer. Observation in the Unit 3 Pantry Refrigerator on September 29, 2025, at 9:47 AM, revealed four containers of applesauce not dated; one can of kidney beans from an outside source open and not properly sealed; and one container of food from an outside source not labeled with a resident's name or date. Interview with the Nursing Home Administrator on October 1, 2025, at 10:40 AM, revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policies, and food storage equipment is utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, observation, manufacturer product information, and staff interviews, it was determined that the facility failed to discard expired medications in a timely manner in one of three medication carts reviewed (Unit 2 Cart 4).Findings include: Review of facility policy, titled Medication Labeling and Storage, with a last review date of May 21, 2025, revealed, in part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy, titled Administering Medications, with a last review date of May 21, 2025 revealed, in part, The expiration/beyond use date on the label must be checked prior to administering. During a medication pass observation on Unit 2 on October 1, 2025, at 9:05 AM, Employee 1 was administering medications from Cart 4. Employee 1 retrieved a house stock bottle of famotidine 10 mg (milligrams) (an over-the-counter medication used to reduce stomach acid) in preparation to administer to Resident 50. Surveyor review of the bottle noted that an open date of March 4, 2025, was written on the bottle and that the manufacturer expiration date was January 2025. Employee 1 was observed confirming the medication name and dose on the bottle to Resident 50's orders, but Employee 1 failed to confirm the expiration date of the medication. During an immediate interview with Employee 1 on October 1, 2025, at 9:08 AM, she confirmed that the bottle was opened three months after the manufacturer expiration date. She also confirmed that there were no other bottles of famotidine in the cart and that staff would have been administering from this bottle. The bottle was approximately one-third full. During a staff interview with the Nursing Home Administrator and Director of Nursing on October 21, 2025, at 11:30 AM, both confirmed that the medication should not have been opened and utilized past the manufacturer expiration date. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(b)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with required included information upon transfer/discharge; failed to provide residents with a copy of the facility's bed hold policy for three of four residents reviewed for hospitalization (Residents 8, 12, and 85).Findings include: Review of facility policy, titled Bed-Holds and Returns last reviewed May 21, 2025, read, in part, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of facility policy, titled Transfer or Discharge, last reviewed May 21, 2025, revealed that subsection titled Transfer or Discharge Documentation in the Medical Record, stated, 1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: .b. That an appropriate notice was provided to the resident and/or legal representative . Review of Resident 8's clinical record revealed diagnoses that included congestive heart failure (disease process that results in the decreased ability of the heart to pump blood through the body effectively) and chronic kidney disease (disease of the kidneys that affects kidney function). Review of Resident 8's clinical record revealed that on June 22, 2025, Resident 8 was sent to the hospital for an acute medical change in condition. Resident was admitted to the hospital and returned to the facility on June 26, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided a notice of transfer or bed hold policy. Resident 8 was also transferred to the hospital for an acute medical change in condition on July 12, 2025. Resident 8 returned to the facility on July 16, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided with a notice of transfer or bed hold policy. Review of Resident 12's clinical record revealed diagnoses that included vascular dementia (changes in the blood vessels of the brain that results in decreased ability to perform activities of daily living and decreased contact with reality) and atrial fibrillation (irregular heartbeat). Review of Resident 12's clinical record revealed that on August 23, 2025, Resident 12 was sent to the hospital after an acute medical change. Review of the available documentation revealed no evidence that Resident 12 nor Resident 12's Representative Party were provided a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. Review of Resident 85's clinical record revealed he was transferred to the hospital for an acute medical change in condition on August 15, 2025. Resident 85 returned to the facility on August 21, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed he was also transferred to the hospital for an acute medical change in condition on August 31, 2025. Resident 85 returned to the facility on September 6, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. During an email correspondence with the Nursing Home Administrator (NHA) on September 30, 2025, at 2:15 PM, the surveyor revealed the concern with the facility not being able to provide the bed hold and transfer notices for Resident 85's aforementioned hospital transfers. The NHA revealed he agreed with the concern about the notices as he does not have proof that they were sent. 28 Pa. Code 201.14(a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services related to the admission and discharge planning process for one of two residents reviewed (Resident 1).Findings include:Review of facility policy, titled Social Assessment, with a last review date of May 21,2025, revealed, in part, A social assessment shall be completed within fourteen (14) days of the resident's admission to the facility. A social assessment will be done to help identify the resident's personal and social situation, needs, and problems. Social services staff will obtain information during the initial interview of the family and upon the resident's admission. The purpose of obtaining this data is to identify information to help staff develop a personalized plan of care that will utilize the individual ' s existing strengths, try to compensate for physical and functional deficits, optimize function and quality of life, and meet the individual ' s needs and preferences.Review of facility policy, titled Social Services, with a last review date of May 21,2025, revealed, in part, The director of social services is a qualified social worker and is responsible for maintaining records related to social services and meeting or assisting with the medically-related social service needs of residents. The social worker/social services staff are responsible for assisting with informing and educating residents, families and representatives about health care options, making referrals and obtaining needed services from outside entities, helping residents with transitions of care services (for example, community placement options, home care services, transfer arrangements, etc.), and identifying and seeking ways to support resident needs through the assessment and care planning process.Review of facility policy, titled Discharge Summary and Plan, with a last review date of May 21, 2025, revealed, in part, Discharge Planning: 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. 2. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. 3. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident ' s discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. 7. A member of the IDT {interdisciplinary team} reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 8. The final discharge plan of care shows what arrangements have been made for the resident regarding: a. where the resident will live after leaving the facility; b. follow-up care the resident will receive from other providers, and that provider's contact information; c. needed medical and non-medical services (including medical equipment); d. community care and support services, if needed; and e. when and how to contact the continuing care provider. In section titled Discharge to the Community: 3. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record.Review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia with behavioral disturbance (cognitive decline accompanied by significant changes in behavior), repeated falls, and generalized muscle weakness. Further review of Resident 1's clinical record revealed that she was discharged home on October 2, 2025.Review of Resident 1's Social Services Evaluation-admission dated September 12, 2025, revealed it was blank. Further review of Resident 1's clinical record failed to reveal any documented social service assessments. Review of Resident 1's care plan revealed a care plan focus for: chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia; impaired visual function; communication problem related to hearing deficit; activities of daily living self-care performance deficit; limited physical mobility; at risk for falls; and Resident wishes to discharge back to the community, all with an initiated date of September 20, 2025. Review of Resident 1's progress notes revealed a physician's history and physical note dated September 14, 2025, at 5:45 PM, that indicated in the Assessment and Plan section that Resident 1 had a fall prior to admission that resulted in facial injuries; that physical therapy would work on balance and transfers; and that she needed 24-hour support secondary to her diagnosis of dementia. Review of Resident 1's progress notes revealed a note dated September 16, 2025, at 2:37 PM, by the Nursing Home Administrator (NHA) that indicated he had met with Resident 1 and that her friend participated by phone. The note further indicated that Resident 1 was doing well with supervision for transfers, was walking 150 feet with her walker and supervision, and needed a lot of cueing. The note also revealed that there was discussion about Resident 1's care needs at home upon discharge and that the plan was to pay privately for home care assistance until she would be eligible to apply for a waiver program.Review of Resident 1's progress notes revealed a physician's progress note dated September 19, 2025, at 12:05 PM, that indicated Resident 1 was still very confused.Review of Resident 1's progress notes revealed a physician's progress note dated September 22, 2025, at 6:54 PM, that indicated Resident 1 was still very confused. The note further indicated that the provider reviewed Resident 1's medications and treatment plan with her POA who was at Resident 1's bedside. The note indicated that Resident 1's plan was to receive short-term rehabilitation services and then be discharged . In addition, the note still indicated that she needed 24-hour support secondary to her diagnosis of dementia. This progress note was the last physician progress note prior to Resident 1's discharge from the facility.Review of Resident 1's progress notes revealed a note dated September 23, 2025, at 2:19 PM, by the NHA that indicated he had made a call to Resident 1's friend and that Resident 1's only barrier is her confusion which they will set up private duty aides. The note also indicated that a discharge was planned for October 2, 2025, unless Resident 1's insurance decided otherwise and that home health would be set up. Review of Resident 1's physician orders revealed an order, dated October 2, 2025, for home health upon discharge for physical therapy and occupational therapy.Review of Resident 1's progress notes between September 23, 2025, and October 2, 2025, failed to reveal any documentation of home health referral(s), if private duty care had been arranged, or if any assistance had been provided with transitions of care services for her discharge back to the community.Review of Resident 1's facility Discharge Summary revealed in the Social Services section that Resident 35 was documented as being occasionally confused; needing occasional cueing; was being discharged home alone and not with a relative or friend; that a referral for home health was made on September 29, 2025, with an order summary sent to the accepting agency; and that she needed to follow up with her primary care physician in 7-10 days after discharge. Documentation failed to include the name or contact information for the home health agency or for her primary care physician.Review of Resident 1's progress note dated October 2, 2025, at 2:38 PM, revealed that she was discharged to home. The note further indicated that Resident 1 was provided her medications, medication summary, and discharge paperwork which was explained to Resident 1 and her family. The note failed to indicate Resident 1's living arrangement post discharge or any information about services that had been organized for her transition back to the community.During an interview with the NHA and the Director of Nursing (DON) on October 21, 2025, at 1:25 AM, the NHA indicated that at the time of Resident 1's discharge, that he and the facility admission Coordinator were covering social service activities as the facility was in the process of hiring a new Social Worker. He said that he had just spoken to the Admissions Coordinator and she indicated that she had forgotten to document the home health referral information for Resident 1. He further indicated that he was aware that Resident 1's Representative (which he identified as a friend of Resident 1) had wanted Resident 1 to apply for a waiver program to receive care assistance at home, but that Resident 1 did not qualify financially. He said that he provided Resident 1's Representative with a list of private duty care providers that she could contact for care assistance at home. He confirmed that he was not aware if this was set up by Resident 1's Representative or not at time of Resident 1's discharge from the facility. He further confirmed that there was no documentation of a review of Resident 1's discharge plan or the assessment of the discharge plan to determine if Resident 1 would have all necessary measures in place that she required to be safe. He also confirmed that no social services assessment was completed during Resident 1's stay at the facility between September 11, 2025, and October 2, 2025, which would have helped with her discharge planning. He revealed that a new social worker had been hired on October 7, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(3) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide and document sufficient preparation to residents to ensure a safe and orderly discharge from the facility; and failed to provide a discharge summary that included a post-discharge plan of care, including post-discharge services, for one of two discharged residents reviewed (Resident 1).Findings include:Review of facility policy, titled Discharge Summary and Plan, with a last review date of May 21, 2025, revealed, in part, 2. The discharge summary provides necessary information for continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. 3. By the time the resident leaves the facility, the discharge summary is furnished to the provider who is assuming responsibility for care of the resident after discharge. 4. The discharge summary may be provided in printed or electronic format. If in electronic format, the receiving provider will acknowledge there is a way to receive and access the discharge summary electronically. 5. The medical record contains a copy of the discharge summary with the identity of the recipient of the summary. In addition, in the section titled Discharge Summary: 1. A discharge summary includes: a. a recapitulation of the resident's stay at the facility (a concise summary of the resident's stay and course of treatment in the facility); b. a final summary of the resident's status at the time of the discharge available for release to authorized individuals and agencies, with the consent of the resident or representative.In section titled Discharge Planning: 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. 2. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. 3. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. 7. A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 8. The final discharge plan of care shows what arrangements have been made for the resident regarding: a. where the resident will live after leaving the facility; b. follow-up care the resident will receive from other providers, and that provider's contact information; c. needed medical and non-medical services (including medical equipment); d. community care and support services, if needed; and e. when and how to contact the continuing care provider.In section titled Discharge to the Community: 3. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record.Review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia with behavioral disturbance (cognitive decline accompanied by significant changes in behavior), repeated falls, and generalized muscle weakness.Further review of Resident 1's clinical record revealed that she was discharged home on October 2, 2025.Review of Resident 1's physician orders revealed an order, dated October 2, 2025, for Home Health upon discharge for physical therapy and occupational therapy. Review of Resident 1's care plan revealed a care plan focus for: chronic/ progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia; impaired visual function; communication problem related to hearing deficit; activities of daily living self care performance deficit; limited physical mobility; at risk for falls; and Resident wishes to discharge back to the community, all with an initiated date of September 20, 2025. Review of Resident 1's progress notes revealed a physician's history and physical note dated September 14, 2025, at 5:45 PM, that indicated in the Assessment and Plan section that Resident 1 had a fall prior to admission that resulted in facial injuries; that physical therapy would work on balance and transfers; and that she needed 24-hour support secondary to her diagnosis of dementia. Review of Resident 1's progress notes revealed a note dated September 16, 2025, at 2:37 PM, by the Nursing Home Administrator (NHA) that indicated he had met with Resident 1 and that her friend participated by phone. The note further indicated that Resident 1 was doing well with supervision for transfers, was walking 150 feet with her walker and supervision, and needed a lot of cueing. The note also revealed that there was discussion about Resident 1's care needs at home upon discharge and that the plan was to pay privately for home care assistance until she would be eligible to apply for a waiver program.Review of Resident 1's progress notes revealed a physician's progress note dated September 19, 2025, at 12:05 PM, that indicated Resident 1 was still very confused.Review of Resident 1's progress notes revealed a physician's progress note dated September 22, 2025, at 6:54 PM, that indicated Resident 1 was still very confused. The note further indicated that the provider reviewed Resident 1's medications and treatment plan with her POA who was at Resident 1's bedside. The note indicated that Resident 1's plan was to receive short-term rehabilitation services and then be discharged . In addition, the note still indicated that she needed 24-hour support secondary to her diagnosis of dementia. This progress note was the last physician progress note prior to Resident 1's discharge from the facility.Review of Resident 1's progress notes revealed a note dated September 23, 2025, at 2:19 PM, by the NHA that indicated he had made a call to Resident 1's friend and that Resident 1's only barrier is her confusion which they will set up private duty aides. The note also indicated that a discharge was planned for October 2, 2025, unless Resident 1's insurance decided otherwise and that home health would be set up. Review of Resident 1's progress notes revealed a note dated September 29, 2025, at 11:14 AM, which indicated that Resident 1's insurance would not cover her stay at the facility after October 2, 2025. Review of Resident 1's progress notes revealed a note dated September 30, 2025, at 11:22 AM, which indicated that Resident 1 was receiving physical therapy when she became unresponsive. The note further indicated that when she was put back to bed, Resident 1 immediately became alert, that her vital signs were at baseline, had no signs of distress noted or reported, and that her provider was made aware. The note failed to indicate that Resident 1's Representative was made aware of the unresponsive episode.Review of Resident 1's progress note dated October 2, 2025, at 2:38 PM, revealed that she was discharged to home. The note further indicated that Resident 1 was provided her medications, medication summary, and discharge paperwork, which was explained to Resident 1 and her family. The note failed to indicate Resident 1's living arrangement post discharge. Review of Resident 1's clinical record revealed no evidence that her discharge destination was identified or assessed to ensure it would meet Resident 1's health and safety needs, that a member of the interdisciplinary team had reviewed the final discharge plan with the Resident and Representative or family at least 24 hours before her discharge, that home health services or private duty services were set up prior to Resident 1's discharge from the facility, or that her Discharge Summary was provided to her care providers for continuity of care purposes. Review of Resident 1's facility Discharge summary dated [DATE], at 2:40 PM, but with actual discharge date of Resident left blank, indicated that the reason for Resident 35's admission to the facility was falls. The instructions indicated that the form and the Order Summary Report must be printed and given to the Resident/Responsible Party upon discharge, and that it must be documented in the progress notes that these items were given to the resident. Further review of Resident 1's facility Discharge Summary revealed in the Social Services section that Resident 35 was documented as being occasionally confused; needing occasional cueing; was being discharged home alone and not with a relative or friend; that a referral for home health was made on September 29, 2025, with an order summary sent to the accepting agency; and that she needed to follow up with her primary care physician in 7-10 days after discharge. There was no documentation noted that included the name or contact information for the home health agency or for her primary care physician.Further review of Resident 1's facility Discharge Summary revealed in the Nursing section that Resident 1 ambulated with a walker, needed assistance with activities of daily living, and that the discharge instructions were provided to Resident 1 as family member/representative was not marked. This section failed to include any documentation about Resident 1 having an unresponsive episode or that this could be a possible care concern at home.Further review of Resident 1's facility Discharge Summary revealed in the Dietary Services section was incomplete except for documentation of Resident 1's admission height and weight.Further review of Resident 1's facility Discharge Summary revealed in the Rehabilitation Services section that she was able to ambulate 250 feet with a rolling walker and stand-by assistance; able to negotiate 8 steps with bilateral handrails and stand-by assistance; that she needed stand-by assist with transfers, dressing, and toileting needs with cueing for completion of tasks; and that she needed minimal assistance with light meal prep.During an interview with the NHA and the Director of Nursing (DON) on October 21, 2025, at 1:25 AM, the NHA indicated that at the time of Resident 1's discharge, that he and the facility admission Coordinator were covering Social Service activities as the facility was in the process of hiring a new Social Worker. He said that he had just spoken to the Admissions Coordinator and she indicated that she had forgotten to document the home health referral information for Resident 1. He further indicated that he was aware that Resident 1's Representative (which he identified as a friend of Resident 1) had wanted Resident 1 to apply for a waiver program to receive care assistance at home, but that Resident 1 did not qualify financially. He said that he provided Resident 1's Representative with a list of private duty care providers that she could contact for care assistance at home. He confirmed that he was not aware if this was set up by Resident 1's Representative or not at time of Resident 1's discharge from the facility. He further confirmed that there was no documentation of a review of Resident 1's discharge plan or the assessment of it to determine if Resident 1 would have all necessary measures in place that she required to be safe. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed (Resident 5).
Findings include:
Review of Resident 5's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition where the kidneys are damaged and can't filter blood as they should) and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high).
Review of Resident 5's hospital referral paperwork revealed an assessment/plan on December 17, 2024, for: will need outpatient, in-lab PSG (polysomnography) with BiPAP (a noninvasive ventilator that helps people breathe by delivering pressurized air through a mask) titration.
Review of Resident 5's hospital referral paperwork revealed an assessment data on December 17, 2024, for the following: Pulmonary following the patient continue BiPAP at night, continue BiPAP at night and as needed during the day.
Review of Resident 5's clinical record revealed the Resident was admitted to the facility on [DATE], at approximately 5:00 PM from the hospital.
Review of Resident 5's clinical record revealed a nurse's progress note on December 18, 2024, at 5:34 PM, that read: Alerted by charge nurse that Resident 5 came from the hospital with discharge paperwork and order for a Bi-PAP at bedtime. No spare Bi-PAP in house, contact made to facility's oxygen supply company, requesting Bi-PAP via phone and email. Unable to deliver bi-PAP until Thursday, December 19, 2024. Verbalized to charge nurse to contact physician for further orders.
Review of Resident 5's clinical record revealed a nurse's progress note on December 19, 2024, at 12:02 AM, that the Resident requested to be sent back to the hospital if the facility could not get a Bi-PAP for the night. Resident 5 was sent back to the hospital.
During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on December 20, 2024, at 10:37 AM, revealed they did receive a referral that mentioned Resident 5 needing a bi-PAP, although the hospital the Resident came from uses Careport for communication of their referrals and do not have any verbal communication with facilities. The DON revealed that herself, the NHA, and Director of Social Services are responsible for reviewing and approving referrals that come in.
28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment that supports infection prevention and control for seven of 25 residents reviewed (Residents 40, 49, 60, 66, 80, 83, and 86); and failed to maintain an accurate data collection system of infection surveillance from January 2024 through August 2024.
Findings Include:
Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of March 2024, revealed Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.
Further review of the policy revealed:
2.
EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.
5.
EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
a.
Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.
b.
Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs.
6.
EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
Review of facility policy, titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, revised May 2023, revealed, when caring for a resident with suspected or confirmed SARS-CoV-2 infection, personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health)-approved N95 mask or equivalent or higher-level respirator, gown, gloves, and eye protection.
Observation of Resident 40 on October 15, 2024, at 11:34 AM, revealed Resident 40 with an indwelling catheter. Observation of Resident 40's room revealed no signage on the door indicating that Resident 40 was receiving EBP.
Review of Resident 49's clinical record revealed that Resident 49 received tube feeding through a G-tube and that Resident 49 has a pressure ulcer (a skin injury caused by prolonged pressure on a specific area of the body) to the left heel.
Observation of Resident 49's room on October 15, 2024, at 11:26 AM, revealed no signage on the door indicating that Resident 49 was receiving EBP.
During an interview with the Director of Nursing (DON) on October 17, 2024, at 10:10 AM, she stated that the aforementioned residents should be on EBP.
Review of Resident 60's clinical record revealed diagnoses that include COVID-19 (Respiratory virus).
Observation of Resident 60's room door on October 15, 2024, at 12:20 PM, revealed a sign that said, Quarantine Room: Gloves, gown, N95, face shield when entering room.
Observation of Employee 12 on October 15, 2024, at 12:20 PM, revealed him walking into Resident 60's room to serve Resident 60 lunch, wearing only an surgical mask and disposable gown for PPE. When Employee 12 was finished in the room, he exited the room and hung his used disposable gown on the PPE cabinet located in the hallway outside of Resident 60's room.
Review of Resident 60's clinical record revealed that Resident 60 had received a positive COVID-19 test on October 10, 2024, at 8:51 PM.
Review of Resident 60's care plan on October 16, 2024, at 12:30 PM, revealed a care plan for Resident 60 is positive for COVID-19, with an intervention of maintain standard and transmission-based precautions, with a date initiated of October 11, 2024.
Interview with the DON on October 17, 2024, at 10:38 AM, revealed that the facility policy should have been followed and appropriate PPE worn.
Observation of Resident 66 on October 15, 2024, at 11:01 AM, revealed the use of an indwelling catheter.
Observation of Resident 66's room door revealed no signage on the door indicating that Resident 66 was receiving EBP.
Review of Resident 80's clinical record revealed diagnoses included hypertension (elevated/high blood pressure) and peripheral vascular disease (disease of the arteries that decreases blood circulation in the extremities).
During a resident interview with Resident 80 on October 15, 2024, at approximately 12:00 PM, it was observed that Resident 80 had a sutured wound of the face.
Observation of Resident 80's room entrance failed to reveal any indication that Resident 80 was on EBP.
Review of Resident 80's physician orders failed to reveal any orders for Resident 80 to be on EBP.
Interview with the DON on October 17, 2024, at 11:30 AM, revealed that the facility policy should have been followed and Resident 80 should have been on EBP because of his medical conditions.
Review of Resident 83's clinical record revealed diagnoses included hypertension and congestive heart failure (CHF disease process that results in decreased ability of the heart to pump blood to the body).
Review of Resident 83's clinical record revealed that Resident 83 had a gastrostomy tube (surgically placed opening to the stomach through the abdominal tissue) for hydration and medication.
Observation of Resident 83's room entrance failed to reveal any indication that Resident 83 was on EBP.
Review of Resident 83's physician orders failed to reveal any orders for Resident 83 to be on EBP.
Interview with the DON on October 17, 2024, at 11:30 AM, revealed that the facility policy should have been followed and Resident 83 should have been on EBP because of his medical conditions.
Review of Resident 86's clinical record revealed diagnoses of pressure ulcer of sacral region (ulcer, caused by pressure, located in the sacral region) and acute kidney failure (AKF a sudden decline in kidney function).
Observation of Resident 86's room door failed to reveal any signage or any other notification that Resident 86 was on EBP. Further observation of Resident 86 at that time revealed the Resident lying in his bed and the Resident had an indwelling catheter.
Review of Resident 86's physician orders failed to reveal any orders for Resident 86 to be on EBP.
Review of Resident 86's care plan failed to reveal any plan of care for Resident 86 to be on EBP.
Interview with the DON on October 17, 2024, at 11:00 AM, revealed that the facility policy should have been followed and Resident 86 should have been on EBP because of his medical conditions.
On October 17, 2024, at 10:08 AM, the DON provided the facility's data collection of infection surveillance for September 2024. She stated that January 2024 through June 2024 was done electronically under the facility's prior ownership and, since the new owners took over, she was unable to access the monthly infection surveillance for January 2024 through June 2024.
In a follow-up correspondence from the DON on October 17, 2024, at 12:52 PM, she stated that, in addition to not being able to access the infection surveillance for January through June, she was also unable to locate the monthly infection surveillance for July 2024 and August 2024.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.1(a)(c)Reportable diseases
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observation, policy review, and staff interviews, it was determined that the facility failed to ensure drugs are stored in locked compartments and only accessible by authorized personnel for two of three resident areas observed (100 Hall and 200 Hall).
Findings Include:
Review of facility provided policy, Disposal of Medications and Medication-Related Supplies, effective July 1, 2023, revealed, all discontinued and unused medications may be disposed of by the facility, and medications to returned to the pharmacy should be secured until the time of pick-up.
An observation on October 15, 2024, at 10:11 AM revealed a round, white object on the floor in a resident's room in the 100 Hall.
An immediate interview with Employee 6 (Registered Nurse), confirmed the round, white object to be a medication (pill) and stated she would attempt to determine the type of medication.
An additional interview with Employee 6 on October 15, 2024, at 12:44 PM, revealed she was unable to determine the name or origin of the medication.
An interview with the Director of Nursing (DON) on October 16, 2024, at 12:45 PM, confirmed she had knowledge of the medication found on the floor in a resident room in the 100 Hall.
Observation of the 200-hall nursing station on October 16, 2024, at 12:30 PM, revealed one round white pill with 210 inscribed on it. The pill was identified as Amlodipine (blood pressure medication) 5 mg tablet.
Interview with Employee 13 (Registered Nurse Supervisor) on October 16, 2024, at 12:30 PM, revealed that a nurse had just been there wasting medication and must have dropped it.
Interview with the DON on October 17, 2024, at 1:35 PM, revealed an expectation that the facility policy would have been followed and the medication would be secured.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services

Based on facility document review and staff interviews, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for five of five employees reviewed (Employees 1, 2, 3, 4, and 5).
Findings Include:
Review of select facility documentation revealed that Employee 1 was hired on November 16, 1999; Employee 2 was hired on January 4, 2019; Employee 3 was hired on March 27, 2007; Employee 4 was hired on September 12, 2011; and Employee 5 was hired on May 1, 2006.
On October 16, 2024, at approximately 8:45 AM, the surveyor was provided with performance evaluations for Employees 2, 3, and 5. Review of the performance evaluations revealed they were all dated as being completed on October 15, 2024. No performance evaluations were provided for Employees 1 and 4.
On October 16, 2024, at 11:05 AM, the Director of Nursing (DON) stated that the facility has been working on updating the performance evaluations because of the recent change in ownership and they were starting staff with a clean slate.
In a follow-up interview with the DON on October 16, 2024, at 11:14 AM, she confirmed that there were no performance evaluations completed prior to October 15, 2024.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.19(2) Personnel policies and procedures

Based on observation, record review, and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for two of 23 residents reviewed (Residents 22 and 72).
Findings include:
Review of Resident 22's clinical record revealed diagnoses that included chronic kidney disease (CKD loss of the ability of the kidneys to remove waste and concentrate urine) and congestive heart failure (CHF when your heart muscle doesn't pump blood as well as it should).
Review of Resident 22's physician orders revealed an order for Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 Unit/milliliter (Insulin Aspart with Niacinamide) Inject as per sliding scale: If 140-180 = 2; 181-240 = 4; 241-300 = 6; 301-350 = 8; 351-400 = 10; if greater than 400 administer 10 units and call physician, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic polyneuropathy, with an order date of April 29, 2024.
Review of Resident 22's July 2024 Medication Administration Record (MAR) revealed on July 1, 2024, at 12:00 PM, Resident 22's blood sugar level was 229, and it was marked that Resident 22 received no units of insulin at that time.
Review of Resident 22's August 2024 MAR revealed on August 14, 2024, at 8:00 AM, Resident 22 had a blood sugar level of 140, and it was marked that Resident 22 received no units of insulin at that time.
Review of Resident 22's October 2024 MAR revealed on October 13, 2024, at 8:00 AM, Resident 22 had a blood sugar level of 269, and it was marked they Resident 22 received no units of insulin at that time.
During an interview with the Nursing Home Administrator and Director of Nursing (DON) on October 17, 2024, at 11:30 AM, they revealed that Resident 22 is care planned for refusing medications, but they would have expected it to have been marked as a refusal on the MARs if Resident 22 had refused insulin during the days listed above.
Review of Resident 72's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and peripheral vascular disease (disease of the arteries that decreases circulation of blood in the extremities of the body).
Review of Resident 72's clinical record revealed that on July 11, 2024, Resident 72 was examined by consultative dental services.
Review of the consultation sheet revealed the dentist documented that Resident 72 had an abscess at the site of an extracted tooth with pus drainage (sign of infection). As a result of the findings, the dentist prescribed clindamycin (an antibiotic medication used to treat infections) 300 milligrams (mg - metric unit of measure) two tablets stat (medical term used to indicate the medication or treatment should be provided right away), then one tablet (equal to 300 mg) four times a day until 29 pills were used.
Review of Resident 72's interdisciplinary progress notes revealed that on July 12, 2024, at 4:41 PM, DON documented, [Resident 72] was seen by dentist on [July 11, 2024] for tooth pain at #6 retained root. Dentist identified an abscess with pus exudate in addition to the pain. Antibiotic order for loading dose followed by QID admin x7days .
Review of Resident 72's medication administration record revealed that Resident 72 did not receive the initial dose of 600 mg of clindamycin.
Review of progress note entered on July 12, 2024, at 10:09 PM, by Employee 19 revealed it stated, The medication [Clindamycin] is on order, spoke with pharmacy they stated the medication [should] arrive by morning.
Review of Resident 72's clinical record revealed that Resident 72 did not receive the initial dose of clindamycin 600 mg. Further, Resident 72 was not started on clindamycin 300 mg four times a day until July 13, 2024, at 6:00 PM.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON revealed that the consultative dental service did not provide the consultation sheet with the order until July 12, 2024; at which time, the order was transcribed. However, the facility did not have clindamycin available at that time and would need the medication delivered from the pharmacy. DON confirmed that there was no documented evidence that Resident 72 received the initial dose of clindamycin 600 mg. Further, since it was not available at the time of administration, an administration prompt in the electronic medication administration record did not occur again.
During the staff interview, DON stated that stat orders are expected to be provided in a time frame no less than four hours.
Review of Resident 72's clinical record revealed that on July 16, 2024, Resident 72 was scheduled for an appointment with an oral surgeon on September 18, 2024, at 3:15 PM.
Review of Resident 72's progress notes revealed that on July 31, 2024, at 8:50 AM, Employee 6 documented, [Employee 6] spoke with [oral surgeon's office staff] she updated this RN that resident will be having teeth extractions on [August 8, 2024] at 10am .[Oral surgeon office staff] advised [Resident 72's] Apixaban needs to be placed on hold 5 days prior to procedure .[Certified Registered Nurse Practitioner] gave [verbal order] to place Apixaban on hold.
Review of Resident 72's clinical record revealed that staff did not hold Resident 72's Apixaban order for five days leading up to the procedure and, as a result, Resident 72 was unable to have the procedure when planned.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON revealed that Resident 72 was sent to the hospital on August 2, 2024, and returned August 3, 2024, and, upon returning, staff did not continue the hold order for Resident 72's Apixaban.
During the staff interview, the DON revealed that staff should have continued the hold order for Resident 72's Apixaban upon returning to the facility on August 3, 2024.
42 CFR 483.25 Quality of care
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on employee file review, policy review, and staff interviews, it was determined that the facility failed to conduct timely, complete, and accurate background investigations for four of five employee files reviewed (Employee 7, 8, 9, and 11).
Findings include:
Review of facility policy, titled Hiring, last reviewed August 16, 2024, revealed section 10 stated, Where appropriate, background investigations may be conducted on persons making application for employment with this facility and on current employees as per regulatory guidelines.
Review of Employee 7's personnel file revealed that Employee 7 was hired by the facility on August 19, 2024.
Review of Employee 7's application submitted to the facility revealed that Employee indicated, Yes, to the question of, Have you ever been convicted of a felony or misdemeanor? Employee 7 did not have anything recorded in the section below the question which stated, If yes, please explain.
Review of Employee 7's personnel file revealed the facility completed a criminal background check through the Pennsylvania State Police on August 27, 2024.
Review of the criminal background check revealed the facility failed to submit the Employee's correct name and the correct date of birth . Further, the submission did not include Employee 7's social security number.
Review of Employee 8's personnel file revealed Employee 8's hire date was August 25, 2024. Review of Employee 8's personnel file revealed the facility did not conduct a criminal background check upon hire. Employee 8's personnel file contained a criminal background check completed on December 20, 2021.
Review of Employee 9's personnel record revealed that Employee 9 was hired on August 16, 2024. Review of Employee 9's personnel record revealed the facility did not conduct a criminal background check upon hire. Employee 9's personnel record contained a criminal background check that was completed on February 7, 2024.
Review of Employee 11's personnel file revealed Employee 11's hire date was July 16, 2024. Review of Employee 11's personnel file revealed the facility did not conduct a criminal background check upon hire. Review of Employee 11's personnel file revealed a criminal background check completed on January 23, 2024.
Further review of Employee 11's personnel record also revealed the facility did not verify that Employee 11's Registered Nurse license was unencumbered (active, with no professional or legal restrictions placed upon the license). Review of Employee 11's personnel record revealed a license verification conducted on January 23, 2024.
During a staff interview on October 16, 2024, Director of Nursing (DON) confirmed that the person who would be responsible for alerting the facility to any criminal convictions or actions taken against a professional license would be the employee.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON confirmed that the facility should conduct criminal background checks and professional license verifications upon hire at the facility.
28 Pa code 201.18(b)(1)(3) Management

Based on observations, facility policy review, manufacturer label review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents with tube feedings reviewed (Resident 19).
Findings include:
Review of facility policy, Enteral Nutrition, revised November 2018, failed to reveal any expectation for labeling an enteral nutrition bottle with the time or date that it was open and placed into use.
Review of Resident 19's clinical record revealed diagnoses of abnormal weight loss (unintentional weight loss or weight loss without trying) and feeding difficulties (difficulties eating, chewing, or swallowing).
Observation of Resident 19 on October 15, 2024, at 10:14 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding hanging. The tube feeding container was not labeled with the time or date that the tube feeding was opened, or when the administration began.
Observation of Resident 19 on October 16, 2024, at 9:52 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding hanging. The tube feeding container was not labeled with the time or date that the tube feeding was opened, or when the administration began.
Review of current physician orders for Resident 19 on October 15, 2024, revealed a current order for Resident 19 to receive enteral feeding, Jevity 1.5 cal (type of enteral feeding) at 60 ml/hr from 6:00 PM until 6:00 AM.
Review of product information for Jevity 1.5 cal, last updated November 9, 2022, revealed, once opened, the product may be used for up to 48 hours after initial connection when clean techniques is used. Otherwise, it should be discarded after no more than 24 hours.
Interview with the Director of Nursing at 12:35 PM, revealed the facility does not have a separate policy that speaks to the labeling and dating of enteral nutrition, but the expectation would be that the nurse would date the bottle when it is placed into use.
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 ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 1).
Findings Include:
Review of Resident 1's clinical record revealed diagnoses that included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness).
Further review of Resident 1's clinical record revealed that she is followed weekly by an outside wound consultant for an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to her sacrum (a triangular bone in the lower back).
Review of Resident 1's wound consult dated July 23, 2024, revealed a new treatment recommendation to cleanse the wound with 0.125% Dakin's solution (wound cleanser), apply Santyl (ointment is used to remove damaged tissue), Silver alginate (a type of dressing) to the base of the wound, and secure with bordered foam.
Review of Resident 1's physician orders revealed an order dated July 23, 2024, to cleanse the sacrum with normal saline solution (NSS), apply Santyl with silver alginate to wound base, and secure with bordered foam. There was no order for the Dakin's solution.
Review of Resident 1's wound consult dated July 30, 2024, revealed the same treatment recommendation that was made on July 23, 2024.
Review of Resident 1's physician orders revealed no new treatment orders were placed after Resident 1's wound consult on July 30, 2024, and the same treatment that was ordered on July 23, 2024, remained in place.
During an interview with the Nursing Home Administrator and Director of Nursing (DON) on August 20, 2024, at 12:34 PM, the DON stated she was unsure why the Dakin's solution wasn't ordered.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of three residents reviewed (Resident 1).
Findings include:
Review of Resident 1's clinical record revealed diagnoses that included congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), gastro esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), and hypertension (high blood pressure).
Review of Resident 1's physicians orders revealed the following medications:
Clopidogrel Bisulfate Oral Tablet 75 mg (milligram- unit of measure), give one tablet by mouth one time a day, with a start date of November 13, 2023.
Famotidine Tablet 20 mg, give one tablet by mouth one time a day, with a start date of May 25, 2024.
Jardiance Oral Tablet 10 mg, give one tablet by mouth one time a day, with a start date of May 10, 2024
MagOx 400 Oral Tablet, give 800 mg by mouth three times a day, with a start date of November 13, 2023.
Metoprolol Tartrate Oral Tablet 25 mg, give 0.5 tablet by mouth every 12 hours, with a start date of November 12, 2023.
Lasix Oral Tablet 20 mg, give one tablet by mouth one time a day, with a start date of November 12, 2023.
Eliquis Oral Tablet, give 5 mg by mouth two times a day, with a start date of January 19, 2024.
Florastor Capsule 250 mg, give one capsule by mouth two times a day, with a start date of November 12, 2023.
Observation in Resident 1's room June 24, 2024, at 9:49 AM, revealed a cup of medications on her bedside table.
During an interview with Employee 1 (Licensed Practical Nurse) on June 24, 2024, at 9:54 AM, the surveyor inquired about the medications being left at Resident 1's bedside. Employee 1 stated she thought Resident 1 had an order that she can self-administer her own medications, and she confirmed that she gave the aforementioned medications that were left on Resident 1's bedside table.
Review of Resident 1's clinical record revealed a Medication Self-Administration Screen, dated January 8, 2024, that stated Interdisciplinary team review of resident's abilities to self-medication administer determined resident is unable to safely administer her medications.
Interview with the Director of Nursing (DON) on June 24, 2024, at 10:42 AM, revealed all of the aforementioned medications were signed off between 9:36 AM and 9:38 AM, and that she would expect medications to not be signed off as administered until after they are taken by the Resident.
Follow-up interview with the DON on June 24, 2024, at 11:22 AM, revealed that Resident 1 will sometime refuse medications because she doesn't like staff to stay and watch her, but that she does not have orders for self-administration and she would expect Resident 1's medications not to be left at the bedside.
28 Pa. Code 201.18(b)(1) Management
28 Pa Code 211.12(c)(d)(1)(5) Nursing Services

Based on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure services provided meet professional standards of quality and practice for one of 21 residents reviewed (Resident 28).
Findings Include:
Review of the facility's policy, titled Self -Administration of Medications, revised December 2016, read Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.
Review of the facility's policy, titled Medication Administration-Preparation and General Guidelines, read Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.
The policy continued, Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Also, The resident is always observed after administration to ensure that the dose was completely ingested.
An observation of Resident 28 in her room, on December 4, 2023, at 10:06 AM, revealed the Resident in bed with a cup of water in one hand and one small medicine cup containing multiple medications in the other hand.
An immediate interview with Resident 28 revealed the licensed practical nurse (Employee 1) provided her the medications and water and exited the room.
An interview with the Director of Nursing on December 6, 2023, at 11:16 AM, revealed Resident 28 has not been assessed to self-administer her medications, and agreed Employee 1 should not have left the medications with Resident 28.
28 Pa. Code 211.12 (d) (1) (2) (5)

Based on observations, clinical record review, and staff interviews, it was determined that the faciliy failed to ensure that the resident enviornment was free of accident hazards two of three residents reviewed for falls (Residents 14 and 35).
Findings include:
Review of Resident 14's clinical record revealed diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and aphasia (loss of ability to understand or express speech, caused by brain damage).
Observation made on December 4, 2023, at 9:51 AM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed.
Observation made on December 5, 2023, at 9:08 AM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed.
Observation made on December 5, 2023, at 1:48 PM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed.
Observation made on December 6, 2023, at 10:15 AM, revealed Resident 14 had a fall mat down on the left side of their bed, while the Resident was lying in bed.
Review of Resident 14's current physician's orders, with last order review date November 29, 2023, revealed an order for bilateral fall mats with the indication being for safety, with the original order date being March 6, 2023.
Review of Resident 14's current comprehensive care plan last reviewed on August 21, 2023, revealed a focus area of: Resident is at risk for falls related to impaired mobility, left side hemiplegia, neuropathy, prescribed medications; with an intervention of: Bilateral fall mats, initiated on February 13, 2023.
Review of a fall incident report on Resident 14 that revealed Resident 14 sustained a fall out of bed on February 11, 2023, at 1:58 PM. The intervention that was for a fall mat to be added to the right side of the bed, will now be on both sides of bed.
Review of a fall risk assessment completed on Resident 14 on February 15, 2023, revealed Resident 14 scored a 10 on the assessment, indicating they are a high risk for falls.
Review of electronic correspondence received from the Nursing Home Administrator (NHA) on December 7, 2023, at 10:07 AM, revealed the facility identified this concern as an issue, and the rehab manager assessed Resident 14's room yesterday (December 6, 2023), and found that the Roommate is upset with Resident 14 having both fall mats down.
During an interview with the NHA on December 7, 2023, at 11:23 AM, revealed that their expectation would have been for Resident 14's bilateral fall mats to be down as ordered by the physician.
Review of Resident 35's clinical record on December 5, 2023, at approximately 1:00 PM, revealed diagnoses including history of cerebral vascular accident (stroke - loss of blood to an area of the brain) with hemiplegia (paralysis of one side) and hemiparesis (muscle weakness of one side), and mild cognitive impairment (decreased ability of decision making, trouble remembering, and/or difficulty with concentration and learning).
During general observations on December 4, 2023, at approximately 11:00 AM, it was observed that the power-cord to a portable HVAC unit (portable unit that heats or cools air) was partially taped to the floor across Resident 35's doorway. Observation of the power-cord revealed some area was loose and moveable.
Review of Resident 35's comprehensive plan of care revealed a care plan with a focus of, .risk for falls [related to] deconditioning, hemiplegia and she will attempt to self ambulate without her walker, which was last revised on September 21, 2023. Review of the interventions for the fall care plan revealed an intervention of, The resident needs a safe environment with: even floors free from spills and/or clutter . Review of Resident 35's care plan for activities of daily living, revealed Resident 35 was independent with transfers (how one moves from the bed, to chair, or chair to standing positions).
Review of Resident 35's most recent fall risk evaluation completed on June 1, 2023, revealed Resident 35 was assessed as High Risk of falls.
Review of Resident 35's nurse aide documentation for walking in her room revealed that on 25 of 30 days reviewed, Resident 35 ambulated independent of staff assistance.
During a staff interview on December 7, 2023, at approximately 11:00 AM, NHA revealed that the HVAC system was portable and that it could be moved to a separate area of the hallway so that the power-cord was not traversing Resident 35's doorway.
42 CFR 483.25(d) Accidents
28 Pa. Code: 201.18(b)(1)(e)(1) Management
28 Pa. Code: 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents pharmacy reviews are acted upon appropriately by the attending physician for four of five residents reviewed for unnecessary medication (Residents 19, 45, 49, and 63)
Findings include:
Review of facility policy, titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report), dated 2006, revealed Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.
Review of Resident 19's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors).
Review of Resident 19's pharmacy recommendation dated July 15, 2023, revealed the consultant pharmacist's recommendation stated, This resident has been receiving Pyridoxine 50 milligrams (mg) twice a day and Valproic Avid 1500 mg once a day for bipolar disorder/depression with psychotic features. The review requested evaluation of the continued need and effectiveness, if determined necessary, to include a risk-vs-benefit analysis.
Review of the pharmacy recommendation revealed that on July 18, 2023, the physician declined the recommendation and failed to provide an explanation.
During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on December 7, 2023, at 11:23 AM, revealed their expectation would have been for the physician to have provided a rationale for declining the pharmacist's recommendation.
Review of Resident 45's clinical record revealed diagnoses that included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and essential hypertension (high blood pressure).
Review of Resident 45's pharmacy recommendation dated March 14, 2023, revealed the consultant pharmacist's recommendation stated, This resident is using the Percocet as needed quite frequently. Please review the usage to determine if a low-dose routine order would be appropriate for treating pain.
Review of the pharmacy recommendation revealed that the physician declined the recommendation and failed to provide an explanation.
During an interview with the DON and NHA on December 7, 2023, at 11:23 AM, revealed their expectation would have been for the physician to have provided a rationale for declining the pharmacist's recommendation.
Review of Resident 49's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
Review of Resident 49's pharmacy recommendation dated August 16, 2023, revealed that Resident 49 was currently receiving two antipsychotic medications, Seroquel and Haldol, and while this therapy may be well suited for the resident, there is the concern of increased side effects with 2 or more similar agents being used for the same condition. If this is clinically relevant, please include a risk-vs-benefit notation.
The physician responded disagree on August 23, 2023, but provided no rationale for the disagreement.
During an interview with the NHA and DON on December 7, 2023, at 11:28 AM, they confirmed the physician should have documented a rationale for the disagreement.
Review of Resident 63's clinical record on December 4, 2023, at approximately 12:00 PM, revealed diagnoses including degenerative disease of the nervous system (disease state with multiple causes that affects balance, movement, talking, breathing, and heart function) and hypertension.
Review of Resident 63's pharmacy recommendation dated April 24, 2023, revealed the consultant pharmacist's recommendation stated, This resident's order for Buspar (medication used to treat anxiety) 5 mg [milligrams - metric unit of measure] is due for assessment in accordance with CMS [Centers for Medicare and Medicaid Services] guidelines for psychopharmacologic medications . The review requested consideration of a gradual dose reduction of the medication.
Review of the pharmacy recommendation revealed that on April 26, 2023, the physician declined with a rational of Hospice [patient].
Review of Resident 63's pharmacy recommendation dated August 16, 2023, revealed the consultant pharmacist's recommendation stated, This resident's order for Zoloft (medication used to treat depression) 25 mg [in the morning] is due for assessment in accordance with CMS guidelines for psychopharmacologic medications.
Review of the pharmacy recommendation revealed that on August 23, 2023, the physician declined with a rational of Hospice.
Finally, on October 14, 2023, the consultant pharmacist made the recommendation to attempt a gradual dose reduction of Resident 63's Buspar 5 mg twice a day in accordance with CMS guidelines for psychopharmacologic medications.
Review of the recommendation revealed that on October 15, 2023, the physician declined with a rational of Hospice.
During a staff interview on December 7, 2023, at approximately 11:00 AM, Regional Director of Clinical Services revealed that the facility has been providing education with physicians on providing appropriate rationales for declining pharmacy recommendations.
28 Pa. Code 211.10(c) Resident care policies

Based on clinical record review, observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 21 residents reviewed (Resident 9).
Findings include:
Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, last revised in March 2018, revealed the following: Resident will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.
Review of the clinical record for Resident 9 revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
During an interview with Resident 9 on December 5, 2023, at 1:32 PM, they revealed that they requested to get out of bed today, but was told by staff the mechanical lift battery was dead so they will get out of bed tomorrow (December 6, 2023). Resident was observed laying in bed during the interview.
During an interview with CNA 1 (CNA - Certified Nurse Aide) on December 5, 2023, at 1:35 PM, revealed that Resident 9 was not assisted out of bed due to the mechanical lift battery being dead, CNA 1 confirmed Resident 9 will get out of bed tomorrow (December 6, 2023). Interview with CNA 1 revealed that the facility has multiple batteries for the mechanical lift.
Review of Resident 9's current comprehensive care plan on December 6, 2023, at 9:36 AM, which was last reviewed on October 2, 2023, revealed an intervention that stated the following: Resident prefers to be out of bed in wheelchair ., with an initiation date of February 19, 2023. Another intervention on Resident 9's current comprehensive care plan revealed the following: Resident to be encouraged to be up in wheelchair for two-three hours at a time; then return to bed to help with would healing to sacrum, with an initiation date of March 27, 2023. Furthermore, Resident 9 has an intervention on their current comprehensive care plan that was initiated on June 17, 2020, that stated, Out of bed to wheelchair as tolerated'
During an interview with the Nursing Home Administrator on December 6, 2023, at 11:22 AM, revealed the facility has plenty of mechanical lift batteries, and that their expectation would have been for the staff to have gotten a charged battery to assist getting Resident 9 out of bed when requested.
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.10(c) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the faciliy failed to ensure the resident assessment was accurate for two of 21 residents reviewed (Residents 10 and 49).
Findings include:
Review of Resident 10's clinical record on December 5, 2023, at approximately 10:00 AM, revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood into the cells) and chronic kidney disease stage 4 (severe decrease in the ability of the kidneys to filter toxins from the blood).
Review of Resident 10's Quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents physical, mental, and psychosocial needs), with an assessment reference date of September 13, 2023, revealed that section N0410 Medications Received, subsection E - Anticoagulants, was coded to reflect Resident 10 had received an anticoagulant medication for seven of seven days of the look-back period.
Review of Resident 10's clinical record revealed that Resident 10 was not receiving an anticoagulant medication during the assessment reference period of the September 13, 2023 Quarterly MDS.
During a staff interview on December 7, 2023, at approximately 11:00 AM, Director of Nursing (DON) confirmed that Resident 10 had not received an anticoagulant, and that the MDS was incorrectly coded.
Review of Resident 49's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Further review of Resident 49's diagnoses revealed the Schizophrenia was dated November 4, 2019, and present on admission to the facility, but not added to the diagnosis list until August 4, 2023.
Review of Resident 49's hospital documentation dated October 31, 2019, revealed that the Resident had a history of paranoid schizophrenia.
Review of Resident 49's quarterly MDS dated [DATE]; annual MDS dated [DATE]; quarterly MDS dated [DATE]; and significant change MDS dated [DATE], all revealed that in section I, Schizophrenia was not coded as a diagnosis.
Review of Resident 49's significant change MDS dated [DATE], revealed that in Section N, it was coded that a gradual dose reduction (GDR) of Resident 49's antipsychotic medication had been attempted on August 16, 2023.
Review of Resident 49's clinical record revealed no evidence of a GDR being attempted on that date.
During an interview with the Nursing Home Administrator and DON on December 7, 2023, at 11:28 AM, it was confirmed that Resident 49 had a diagnosis of Schizophrenia in 2019, was missed being placed on the diagnosis list, and, therefore, was missed being placed on the MDS assessments. It was also confirmed that the GDR was incorrectly coded on the September 22, 2023, MDS, as no GDR was attempted.
28 Pa Code 211.5(f)(vi) Medical Records
28 Pa Code 211.12 (d)(3)(5) Nursing Services