Chestnut Hill Lodge Health And Rehab Ctr

Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure timely notification to the physician of fall incident sustained by Resident R1. This failure resulted in actual harm to Resident R1 who experienced a delay of treatment after a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures for one of four residents reviewed. This deficiency is being cited as past non- compliance. (Resident R1) Findings include: Review of facility policy titled, 'Change of Condition' revised June 28, 2023, revealed, if the nurse aide (CNA) identifies a change in resident's condition, they will immediately notify the nurse of the situation, and the resident, attending physician and resident representative, if applicable, will be notified promptly of a significant change in condition, accident/incident, change in treatment, and/or transfer/discharge. Review of facility policy titled, 'Falls Prevention and Management' revised January 12, 2023, revealed the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining casual factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Continued review of same policy revealed, in the event a resident has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Resident is not to be moved until assessed for injury by an RN (Registered nurse) unless life-threatening situation exists. Remain with the resident while calling for assistance, if at all possible. If the resident is unconscious, has difficulty breathing or a severe injury is suspected, immediately call 9-1-1 (Emergency Medical Services) for transfer. Review of Resident R1's clinical record revealed medical history of traumatic hemorrhage of cerebrum (subsequent encounter), altered mental status, Cerebral Infarction (stroke) due to embolism (obstruction of an artery, typically by a clot of blood) of left cerebellar artery, age-related Osteoporosis (decreased bone density), muscle wasting and Encephalopathy (general term for brain disease, damage, or dysfunction, resulting in altered mental state, confusion, personality changes, and potential coma), mobility and gait abnormalities, Dementia (progressive degenerative disease of the brain), restlessness and agitation, Paranoid Personality Disorder, and muscle weakness. Review of Resident R1's physician orders revealed an order, initiated December 20, 2025, for 1:1 (one resident to one staff) monitoring secondary to falls, every shift. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's care needs) completed on December 25, 2025, revealed Resident R1 required partial/moderate assistance for tub/shower transfer: helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Continued review of resident's MDS revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 3 which indicated the resident was severely cognitively impaired. Review of Resident R1's care plan initiated November 13, 2024 revealed care plan developed for fall related to episodes of confusion which include interventions of 1:1 nursing supervision at all times, visual cues will be added to resident's room to encourage the use of the call bell, anticipate and meet resident's needs, ensure call light is within reach and keep frequent used items within reach, Review of Resident R1's nursing notes dated February 7, 2026, (9:42 p.m.) revealed the resident was noted with left side facial swelling and bruising and nosebleed from the left nostril. Pressure was applied to left nostril to stop the bleeding. The resident was not complaining of pain when (her/his) face was touched. An order was obtained to send the resident to the emergency room. 9-1-1 (Emergency Medical Services) was called and Resident R1 was transported to the hospital for evaluation. Continued review of Resident R1's nursing notes dated February 7, 2026, (9:18 p.m.) revealed Resident observed lying on the couch as EMT's (Emergency Medical Technician) arrived to pick resident up. Observed resident with swelling and bruising over the left mandibular (lower jaw). Area feels tender with no complaints or signs of pain observed or verbalized by resident. Resident unable to tell this writer what happened to (her/his) face Unable to assess the rest of (her/his) body as resident was leaving to go to the hospital. Resident was able to stand up with minimal assist onto the stretcher, guardian notified by shift supervisor. Left for [local hospital]. Review of facility documentation submitted to the State Survey Agency on February 7, 2026, revealed Resident R1 was observed with swelling and bruising on the left side of (her/his) face by nursing supervisor. The physician was called and gave order to send the resident to the hospital for further evaluation. The resident was sent to the hospital via 911 (Emergency Medical Services). Resident R1 has imaging done in the ER (emergency room) which revealed a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone). Review of facility provided investigation report related to fall incident sustained by Resident R1 during evening shift on February 7, 2026, revealed Resident R1 sustained a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone), and acute right 3rd - 4th rib fractures. Review of statement completed by Nurse aide, Employee E1, who was assigned to Resident R1 for continuous 1:1 supervision on February 7, 2026 evening shift, revealed I didn't see (her/him) fall, I saw the swollen and the bruise on the left side of the face, after dinner. I did not look at face. Review of additional statement completed by Nurse aide, Employee E1 dated February 9, 2026, revealed at 4:15 p.m. on February 7, 2026, I took (her/him) in the shower room, shower (her/him). After taken (her/him) from the shower chair (she/him) slip and fall on (her/his) left side and I was on (her/his) right side. I did not see any injury. I took (her/him) in the dining room and (she/him) went to sleep on the couch or chair. Review of investigation statement completed by Nurse aide, Employee E3, on February 7, 2026, revealed at approximately 6:00 pm, Resident R1 was noted with nosebleed in dining area of memory care unit; Employee E3 brought the resident to the nurses' station, informed the licensed nurse and nurse aide of Resident R1's nosebleed. Interview with Licensed nurse, Employee E2, who had oversight of memory care unit during evening shift on February 7, 2026, revealed that she was not aware of Resident R1's facial swelling, bruising and/or bleeding until 7:30 p.m. when Nursing Supervisor, Employee E4 notified her. Further review of investigation report revealed, Nursing Supervisor, Employee E4 arrived on the memory care unit, February 7, 2026, for her 7 p.m. shift. While doing rounds approximately 7:15 p.m., she noticed Resident R1 sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Further review of Nursing Supervisor, Employee E4's statement revealed the nurse aide assigned to the Resident R1's 1:1 monitoring, (Employee E1), alleged she did not know what happened to the resident. When Employee E4 asked the agency charge nurse, Employee E2, about the injuries, the nurse responded angrily and told Employee E4 to ask Employee E1, indicating she had 30 residents to oversee. Continued review of Employee E4's statement revealed, Employee E4 questioned why the nurse had not noticed the injuries after giving the resident medication earlier. The discussion escalated into an argument about responsibility for assessing residents and reporting possible abuse or injuries. Nursing supervisor, Employee E4 then removed the agency nurse from the building and contacted local police and the Director of Nursing regarding Resident R1's injuries. Continued review of Nursing Supervisor, Employee's E4 statement the Nursing supervisor, Employee E4 re-assessed the resident, whose nose continued to bleed, and contacted the Nurse Practitioner (NP). The NP instructed Employee E2 to call 911 (Emergency Medical Services) and send the resident to the hospital for evaluation. Review of interview statement from the Nursing Home Administrator (NHA), Employee E7 on February 9, 2026, at 1:35 pm, revealed the NHA asked Nurse aide, Employee E1 to explain what happened while she was providing one to one (1:1) care to Resident R1. Nurse aide, Employee E1 initially said there was no incident. NHA informed Nurse aide, Employee E1 that Resident R1 had reported, through an interpreter, that she fell because the floor was slippery. NHA also stated that Nursing aide, Employee E3 noticed Resident R1's nose bleeding around 6:00 PM and took Resident R1 for evaluation. Nursing Home Administrator reminded Nurse aide, Employee E1 that her responsibility during the Sunday 3 PM shift was to closely watch Resident R1 on a 1:1 basis to prevent a fall. Further review of written statement of an interview conducted between the NHA and Nurse aide, Employee E1 revealed that Nursing Home Administrator confronted Nurse aide, Employee E1 because he believed something had happened to Resident R1 during Nurse aide, Employee E1's 1:1 supervision of Resident R1. During the NHA's follow up interview with Nurse aide, Employee E1 it was revealed during the interview that Nurse aide, Employee E1 admitted that Resident R1 slipped and fell while getting up from a shower chair. Employee E1 stated that Resident R1 did not appear to be in pain, so she helped dry the resident and took (her/him) to the dining room for dinner. Nurse aide, Employee E1 explained she did not report the incident because she was afraid, she would get into trouble. Interview conducted on March 10, 2026, at 2:00 p.m. with the Director of Nursing, Employee E8 and Nursing Home Administrator Employee E7 confirmed nurse aide, Employee E1 failed to notify licensed nursing staff of Resident R1's fall and injuries sustained by the resident. This deficiency was identified as actual harm past non-compliance for Resident R1 experiencing a delay in treatment after sustaining a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures. The facility presented documentation indicating that the facility initiated a plan of correction to address the failure of the facility to provide timely notification after a fall sustained by resident. The facility alleged a date of compliance of February 9, 2026. The plan of correction stated the following: -On 2/27/2026 on 2/7/26 at approximately 7pm Resident R1 was noted to have swelling and bruising on the left side of (his/her) face by nursing supervisor, The supervisor asked the aide (Employee E1) what happened but aide indicated she didn't know. The DON was made aware and investigation was immediately started. Resident R1 was sent to the ER (Emergency Room) for Evaluation.-At approximately 10:30 pm the DON received a call from the hospital stating Resident R1 had a fracture of the mandible and 2 fractured right ribs and chronic subdural hemorrhage.The 1-1 aide assigned to Resident R1 at the time was suspended pending investigation. The police were contacted and came to the facility. 2/7/2026 In-servicing was started on abuse and reporting of incidents and accidents 2/9/2026- Head to toe skin and body checks were completed and all the resident residing on the Unit that Resident R1 resides. Interviews were also conducted with residents that could be interviewed to rule out abuse. 2/9/2026- Employee E1 was called in again to be interviewed regarding this resident since she was the 1-1 and nothing was noted prior to her taking over the 1-1 assignment. After lengthy discussion Employee E1 admitted that Resident R1 fell in the shower room, she stated she was afraid to report the fall.Employee E1 was educated on reporting of any incident and accidents.Employee E1 was terminated for failure to report and incident/accident.In-servicing- continued in the building to all staff on reporting falls and abuse and reporting abuse. Competencies were also given to staff after the education was done abuse.An audit of the last 2 weeks of nurse's notes and shift reports was conducted to ensure any accidents/incidents were reported per policy.The DON/ Designee will audit nurses' notes and shift reports to ensure any accidents and incidents were reported with the appropriate follow up action completed. Audits will be conducted weekly x 4 weeks and then monthly x2. Results of these audits will be submitted to QAPI to determine if further action is needed. Facility educated staff on types of abuse and reporting abused upon learning or hearing of abuse towards a resident and that every employee is expected to report it as soon as possible. Facility education record and subsequent audits were verified for completion. Skin checks documentation was reviewed and completed. Facility provided evidence of audits of nurses' notes for accidents/incidents and abuse audit of non-interviewable residents. Staff were interviewed to verify education. QAPI (Quality Assurance Improvement Plan) records reviewed to verify ongoing monitoring. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c)(d)(1)(3)(5) nursing services

Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure that Resident R1 was free of neglect. This failure resulted in actual harm to Resident R1 who sustained a fall in the shower room with resulting physical injuries; delay in timely assessment and medical treatment for one of four residents reviewed. This deficiency was cited as past non compliance,(Resident R1)Findings include: Review of facility policy 'Falls Prevention and Management,' revised January 12, 2023, indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining casual factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Continued review of the policy revealed that in the event a resident has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Resident is not to be moved until assessed for injury by an RN (Registered nurse) unless life-threatening situation exists. Remain with the resident while calling for assistance, if at all possible. If the resident is unconscious, has difficulty breathing or a severe injury is suspected, immediately call 9-1-1 (Emergency Medical Services) for transfer. Review of Resident R1's clinical record revealed medical history of traumatic hemorrhage of cerebrum (subsequent encounter), altered mental status, cerebral infarction due to embolism (obstruction of an artery, Typically by a clot of blood) of left cerebellar artery, age-related osteoporosis (decreased bone density), muscle wasting and encephalopathy (general term for brain disease, damage, or dysfunction, resulting in altered mental state, confusion, personality changes, and potential coma), mobility and gait abnormalities, dementia (progressive degenerative disease of the brain), restlessness and agitation, paranoid personality disorder, and muscle weakness. Review of physician orders revealed an order obtained December 20, 2025, for 1:1 (one to one staff) monitoring secondary to falls, every shift. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's care needs) completed on December 25, 2025, revealed Resident R1 required partial/moderate assistance for tub/shower transfer: helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Continued review of resident's MDS revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 3 which indicated that the resident was cognitively impaired. Review of Resident R1's care plan initiated November 13, 2024, revealed a care plan developed for fall related to episodes of confusion which include interventions of 1:1 nursing supervision at all times. Review of facility documentation submitted to the State Survey Agency on February 7, 2026, revealed that Resident R1 was observed with swelling and bruising on the left side of (her/his) face by nursing supervisor. The physician was called and gave order to send the resident to the hospital for further evaluation. The resident was sent to the hospital via 911 (Emergency Medical Services). Resident R1 has imaging done in the ER (emergency room) which revealed a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone). Review of investigation report revealed that Nursing supervisor, Employee E4 arrived to memory care unit on February 7, 2026, for her 7 PM shift. While doing rounds around 7:15 PM, she noticed Resident R1 sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Continued review of the Nursing supervisor, Employee E4's statement revealed that the nurse aide assigned to the resident's 1:1 monitoring, (Employee E1), said she did not know what happened to the resident. When Employee E4 asked the agency charge nurse, Employee E2, about the injuries, the nurse responded angrily and told her to ask Employee E1, stating she had 30 residents to manage. Nursing supervisor, Employee E4 questioned why the nurse had not noticed the injuries after giving the resident medication earlier. The discussion escalated into an argument about responsibility for assessing residents and reporting possible abuse or injuries. Nursing supervisor, Employee E4 then removed the agency nurse from the building and contacted the local police and the Director of Nursing. Continued review of Nursing Supervisor, Employee E4's statement noted that after the agency charge nurse, Employee E2 left the facility, the Nursing supervisor, Employee E4 re-assessed the resident, whose nose continued to bleed, and contacted the Nurse Practitioner (NP). The NP instructed Employee E2 to call 911 (Emergency Medical Services) and send the resident to the hospital for evaluation. Review of the written statement by Nurse aide, Employee E1, who was assigned to Resident R1 for continuous 1:1 supervision on February 7, 2026, during the evening shift. I didn't see (her/him) fall, I saw the swollen and the bruise on the left side of the face, after dinner. I did not look at face. Review of interview statement from the Nursing Home Administrator (NHA), Employee E7 on February 9, 2026, at 1:35 pm, revealed the NHA asked Nurse aide, Employee E1 to explain what happened while she was providing one to one (1:1) care to Resident R1. Nurse aide, Employee E1 initially said there was no incident. NHA informed Nurse aide, Employee E1 that Resident R1 had reported, through an interpreter, that she fell because the floor was slippery. NHA also stated that Nursing aide, Employee E3 noticed Resident R1's nose bleeding around 6:00 PM and took Resident R1 for evaluation. Nursing Home Administrator reminded Nurse aide, Employee E1 that her responsibility during the Sunday 3 pm shift was to closely watch Resident R1 on a 1:1 to prevent a fall. Further review of written statement of the interview conducted between the NHA and Nurse aide, Employee E1 revealed that Nursing Home Administrator confronted Nurse aide, Employee E1 on February 9, 2026 because he believed something had happened to Resident R1 during Nurse aide, Employee E1's 1:1 supervision. Nurse aide, Employee E1, admitted during interview that Resident R1 slipped and fell while getting up from a shower chair. Employee E1 stated that Resident R1 did not appear to be in pain, so she helped dry the resident and took (her/him) to the dining room for dinner. Nurse aide, Employee E1 explained she did not report the incident because she was afraid, she would get into trouble. Further review of the documentation submitted to the State Survey Agency of the investigation of possible neglect sustained by Resident R1, revealed that the facility substantiated the allegation of neglect due to nurse aide, Employee E1 failure to report the fall incident to the nurse. Nurse aide, Employee E1 was terminated for failure to report an accident/incident involving Resident R1. Interview conducted on March 10, 2026, at 2:00 p.m. with the Director of Nursing, Employee E8 and Nursing Home Administrator Employee E7 confirmed that nurse aide, Employee E1 failed to notify licensed nursing staff of Resident R1 fall incident and injuries sustained by the resident. The facility presented documentation indicating that the facility initiated a plan of correction to address the failure of ensuring timely notification to the physician of a fall incident sustained by Resident R1, which resulted in actual harm to Resident R1 who experienced a delay of treatment after the fall incidents with injuries. The facility alleged a date of compliance of February 9, 2026. The plan of correction stated the following: -On 2/27/2026 on 2/7/26 at approximately 7pm Resident R1 was noted to have swelling and bruising on the left side of her face by nursing supervisor, The supervisor asked the aide (Employee E1) what happened the aide state she didn't know. The DON was made aware and investigation was immediately started. Resident ER1 was sent to the ER for Evaluation.-At approximately 10:30 p.m. the DOB received a call from the hospital stating the Resident R1 had a fracture of the mandible and 2 fractured right ribs and chronic subdural hemorrhage.-The 1-1 aide assigned to this resident at the time was suspended pending investigation. The police were called and came to the facility. 2/7/2026 In-servicing was started on abuse and reporting of incidents and accidents 2/9/2026- Head to toe skin and body checks were completed and all the resident residing on the Unit that Resident R1 resides on. Interviews were also conducted with residents that could be interviewed to rule out abuse. 2/9/2026- Employee E1 was called in again to be interviewed regarding this resident since she was the 1-1 and nothing was noted prior to her taking over the 1-1 assignment. After lengthy discussion Employee E1 admitted that Resident R1 fell in the shower room, she stated she was afraid to report the fall.Employee E1 was educated on reporting of any incident and accidents.Employee E1 was terminated for failure to report and incident/accident.In-servicing- continued in the building to all staff on reporting falls and abuse and reporting abuse. Competencies were also given to staff after the education was done abuse.An audit of the last 2 weeks of nurse's notes and shift reports was conducted to ensure any accidents/incidents were reported per policy.The DON/ Designee will audit nurses' notes and shift reports to ensure any accidents and incidents were reported with the appropriate follow up action completed. Audits will be conducted weekly x 4 weeks and then monthly x2. Results of these audits will be submitted to QAPI to determine if further action is needed. Facility education record and subsequent audits were verified for completion. Skin checks documentation was reviewed and completed. Facility provided evidence of audits of nurses' notes for accidents/incidents and abuse audit of non-interviewable residents. Staff were interviewed to verify education. QAPI (Quality Assurance Improvement Plan) records reviewed to verify ongoing monitoring. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility provided documentation, review of clinical records and interview with staff, it was determined facility did not ensure to complete medication regimen reviews according to professional standards of practice for two of five residents reviewed (Residents R3, and R8) Findings include: Review of facility policy 'Medication Regimen Review,' reviewed in May 2025, indicates that the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical. Review of facility provided 'Consultant Pharmacist's Medication Regimen Review,' for recommendations created between August 1, 2025, and August 6, 2025, revealed that dose reduction was recommended for Resident R3 related to Abilify prescription. Further review of 'Consultant Pharmacist's Medication Regimen Review,' revealed no evidence of physician rationale for Resident R3. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between July 1, 2025, and July 16, 2025, revealed recommendation for Resident R8, stating Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Lexapro order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this Consultant Pharmacist's Medication Review Regimen revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between August 1, 2025, and August 6, 2025, revealed recommendation for Resident R8, stating Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Risperdal order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this Consultant Pharmacist's Medication Review Regimen revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Interview with Employee E7, Medical Director confirmed findings. 28 Pa Code 211.9(k) Pharmacy services 28 Pa Code 211.12(d)(3) nursing services

Based on review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to accurately document resident council concerns as grievances, failed to record follow-up actions and resolutions in resident council minutes, and did not ensure that residents were informed of outcomes, affecting the resident council's ability to function as a formal grievance forum for 7 of 19 residents in resident council attendance. (Resident 33, R44, R70, R85, R152 and R167) Findings include:Review of facility policy titled Clinical Manual - Social Services Manual (last reviewed April 2025) revealed that resident council meetings must be held at least monthly and serve as the formal, legally mandated forum for residents to voice concerns regarding care, treatment, and living environment. The policy requires that all concerns raised during resident council meetings-whether individual or collective-be treated as grievances, followed in accordance with the facility's grievance policy, and communicated back to residents. The policy requires that resident council minutes accurately document concerns raised, actions taken, and follow-up, serving as the official written record of grievances and their resolution. Addressing concerns verbally without documentation does not meet policy requirements.Review of resident council meeting minutes for the previous three months dated September 24, 2025; October 28, 2025; and November 28, 2025, revealed that concerns were consistently documented as no concerns across multiple departments, with minimal notation of issues and no documentation of grievance follow-up or resolution.September 24, 2025: Minutes documented attendance and departmental reports indicating no concerns. Maintenance noted a toilet seat issue on E Wing was fixed or would be fixed. No grievances or documented follow-up actions were recorded.October 28, 2025: Minutes documented attendance and one housekeeping concern marked as resolved. All other departments documented no concerns. No documentation of grievance tracking, corrective actions, or communication back to residents was recorded.November 28, 2025: Minutes documented attendance with all departments indicating no concerns. No grievances or follow-up actions were recorded.Interview with seven residents (R33, R44, R70, R85, R152, R164, and R167) during the resident council meeting held on December 30, 2025, at 10:30 a.m. revealed that residents voiced multiple ongoing concerns related to food services, staffing, physical therapy, supplies, and environmental issues. Residents stated that these concerns are raised repeatedly during monthly resident council meetings and are not resolved or communicated back to residents.Interview with the Activities Director Employee E3 on December 30, 2025, at 1:40 p.m. revealed that she attends all resident council meetings and confirmed that residents voice concerns during meetings. She stated that she does not include these concerns in the resident council minutes if she addresses them verbally during the meeting or if she completes a separate grievance form and forwards it to Social Services. She confirmed that grievances raised during resident council meetings are not consistently documented in the meeting minutes.Review of the resident and family grievance log revealed grievances that were not reflected in resident council minutes:September 2025: Grievances related to nursing care, customer service, missing items, and food services were documented in the grievance log but not in the September 24, 2025 resident council minutes.October 2025: Grievances related to housekeeping, customer service, nursing care, missing items, and medication issues were documented in the grievance log but not in the October 28, 2025 resident council minutes.Interview with Resident R33 on December 30, 2025 at 10:55 a.m. confirmed that resident council minutes were inaccurate. The resident stated she takes personal notes at every meeting and that complaints and concerns are consistently raised but are not reflected in the official resident council minutes. Review of attendance records confirmed Resident R33 attended the resident council meetings.28 Pa. Code 201.18 (e)(3) Management28 Pa. Code 201.29 (a) Resident Rights

Based on clinical record review, staff interviews, and incident/accident documentation, the facility failed to demonstrate that it conducted a thorough, timely, and documented investigation into an allegation of misappropriation of resident property, for one of 33 residents reviewed. (Resident R70) Findings include: Review of the facility's policy titled Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices last reviewed October 2025 revealed the facility requires that all incidents and adverse occurrences be fully, timely, and thoroughly investigated until a clear conclusion is reached. An investigation is considered incomplete if required information, documentation, analysis, or approvals are missing.Key points related to incomplete investigations include:Immediate initiation is mandatory: All incidents involving injury, abuse, neglect, mistreatment, or unknown origin must be reported immediately to the DON and Administrator, and an investigation must begin without delay.Comprehensive data collection is required: Incomplete investigations may result from missing incident reports, unsigned or unreviewed witness statements, lack of resident assessments, missing timelines, or failure to identify all parties involved. The policy requires collection of factual witness statements, environmental observations, resident assessments, and supporting documentation.Required review and oversight: Incident reports and investigations must be reviewed by supervisory staff (Unit Manager, DON, ADON, NHA). Failure to obtain required reviews, signatures, or approvals (including regional or executive approval for reportable events) renders the investigation incomplete.Analysis and conclusions must be documented: An investigation is not complete unless it includes documented conclusions addressing:How the incident occurredWhy it occurred (if determinable)Whether it was preventableRoot cause analysis, when possibleFollow-up actions are required: Immediate corrective actions, care plan revisions, and prevention measures must be documented. Missing or unimplemented corrective actions indicate an incomplete investigation.Additional investigation when needed: If facts are insufficient, abuse is suspected, or reasonable cause cannot be established, the policy requires continued investigation, additional statements, and escalation to the DON, Administrator, and appropriate agencies.Final review and closure: Investigations must be finalized, signed, logged, and trended. Incomplete investigations may occur if documentation is not returned for final review, not forwarded for required signatures, or not included in tracking and QAPI review.Review of documentation reported to the State Survey Agency relate to Resident R70 misappropriation of resident property, revealed that the resident contacted social services on December 8, 2025 and notified the Social Service Director that on November 24, 2025, someone came into a room claiming to be a social worker and took her debit card an ID and had her sign some forms. Resident R33 reported that she received a notification on November 26, 2025 from her bank stating that they suspected fraudulent activity. Resident claims $400 was spent out of her account. In conclusion, the bank has reimbursed the money to her account and issued her new card, an investigation was started, the police and Protective Services were contacted.Continued review of reported incident revealed Resident R70 could not identify the person that came into a room only that it was a female and wore a business suit. The Nursing Home Administrator (NHA), Employee E1 instructed staff who do not dress in scrubs to visit this resident while rounding on December 9, 2025 and December 10, 2025. The resident did not recognize any of the employees.Review of the facility's investigation included a police report, the statement of Resident R33 to Social Services, and the Social Services initial assessment of Resident R70, which indicated the resident scored 15 on the BIMS (brief interview of mental status), reflecting intact cognition.The facility concluded that the NHA, Employee E1 was unable to substantiate that the purchase on the resident's card resulted from someone taking it while at the facility, noting that the resident could not provide a description of the alleged individual or identify anyone involved.The investigation did not include interview with other potential witnesses.Interview with NHA, Employee E1, on January 5, 2025, at approximately 9:00 a.m., acknowledged that the resident reported money missing and initially alleged that an individual presenting as a facility employee entered her room and took her funds. Employee E1 stated that the resident's account changed multiple times, including claims that the withdrawals occurred outside the facility, possibly related to a motel stay prior to admission, and later speculation that the individual may not have been a facility employee.NHA, Employee E1 further stated that the facility did not have further involvement because law enforcement and the bank would not release additional information without a subpoena. He believed the incident did not occur within the facility. Based on the resident's changing descriptions, he informally showed the resident several staff members who might match her description but stated the resident was unable to identify anyone. He acknowledged that the resident could not consistently describe the alleged individual and that no staff member matched the description provided. Employee E1 confirmed that while he spoke generally with staff and followed up with the resident, there was no clear documentation of a comprehensive internal investigation, including:A documented timeline of events,Review of staff schedules and sign-in logs,Interviews with other residents on the unit,Identification of potential witnesses,Documentation of investigative findings and conclusions. 28 Pa. Code 201.18(b)(3) Management

Based on observation, clinical record review, and staff interview, the facility failed to ensure a comprehensive assessment was completed upon admission for one of eight residents reviewed. (Resident R 175)Findings include: Review of Resident R175's admission Minimum Data Set (MDS- assessment of resident care needs) dated December 17, 2025, revealed that the resident entered the facility on December 11, 2025, with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R 175's clinical record primary diagnosis did not include any visual deficit or legal blindness. Interview with Registered Nurse Assessment Coordinator, Employee E5 confirm that Resident R175 was legally blind and confirmed that it was not coded on the diagnosis list of the MDS. 28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policy and interview with staff and residents, it was determined that facility failed to develop and implement a comprehensive resident centered care plan for three of 33 residents reviewed. (Residents R69, and R175) Findings include: Review of the facility policy titled Care Planning Process and Care Conference, last reviewed May 2025, revealed the facility is required to develop and implement a comprehensive, resident-centered interdisciplinary care plan based on each resident's assessed needs, diagnoses, and functional limitations. The policy requires the care plan to be initiated upon admission and updated following completion of the comprehensive assessment, with revisions made for any change in the resident's condition. The policy further requires the facility to identify and care plan for each resident's diagnoses and impairments, including visual deficits or blindness, and to develop individualized, measurable goals with specific interventions. Each identified care plan problem must include assigned responsible disciplines, target dates, and interventions designed to promote resident safety, independence, and quality of life. An interdisciplinary team must develop the comprehensive care plan within 21 days of admission, and all staff are required to provide care in accordance with the care plan. Failure to assess, develop, implement, or revise care plans to address identified diagnoses, such as visual impairment or blindness, is inconsistent with facility policy and the requirements. Review of Resident R175's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R175's care plan did not include a specific problem, goal, or individualized interventions addressing legal blindness. Interview with the Unit Manager Nurse, Employee E9 on January 4, 2026, confirmed the resident is legally blind and confirmed the care plan does not specifically address the resident's visual impairment or include interventions to improve safety and comfort related to blindness. Review of Resident R69's clinical record revealed medical diagnosis of cerebral infarction (stroke), hemiplegia (paralysis) affecting right nondominant side, need for assistance with personal care. Observations of Resident R69 on December 29, 2025, at 10:30 am, revealed resident laying on his right side with right arm underneath him. Interview with facility's Rehabilitation Director, Employee R4, on Friday, January 2, 2026 at 11:30 am, revealed that Resident R69 was to have pillow prop up in bed under right upper extremity. Review of occupational therapy notes, dated December 3, 2025, indicated that Clinician provided education regarding wearing R (right) sling when in therapy or out of bed for increased comfort. Review of R69's care plan revealed no evidence of interventions related to pillow and sling provision for resident's comfort. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12 (c) (d)(1)(3)(5) Nursing services

Based on review of clinical records, facility schedules, staff interviews, and observations, it was determined that the facility failed to ensure residents were provided bathing and showering services in accordance with their assessed needs and physician orders for six of eight residents reviewed. (Residents R33, R43, R174, R164, R185, R180)Findings include: Review of facility policy titled ADL Care Bathing (shower, tub, bed, perineal) last reviewed March of 2025, revealed that the facility requires residents be offered bathing or showering at least weekly, based on resident preference and care plan orders. The policy further requires that refusals, missed care, or barriers to providing ADL services be documented and reported to licensed nursing staff. The facility failed to follow its own policy by not offering scheduled showers, inaccurately reporting resident refusals, and failing to document missed care or resident preferences. Review of facility shower schedules and ADL (activities of daily living) documentation for the CD Nursing Unit revealed multiple residents were scheduled to receive showers during the 7:00 a.m. to 3:00 p.m. shift on December 29, 2025, including Residents R172, R43, R174, R164, R185, R69, and R180. Documentation did not reflect that showers were completed as scheduled, nor did it contain documented refusals or clinical justifications for missed care. Observation of the CD Nursing Unit shower room at approximately 11:45 a.m. on December 29, 2025, revealed the shower room was completely dry and being used for storage of floor lifts. There was no evidence that the shower room had been used for resident bathing on that date. During an interview conducted with the Licensed nurse Unit Manager E9, on December 29, 2025, at approximately 11:50 a.m., the surveyor was provided with the shower schedule indicating residents were assigned to receive showers that morning on the 7:00 a.m. to 3:00 p.m. shift. Interview with Nurse aide, Employee E10 on December 29, 2025 at approximately 12:05 p.m. revealed she was preparing to provide Resident R174 with a bed bath at the time of interview and the other residents declined a shower today. Interview with Nursing Aide, Employee E11 at 12:10 p.m. revealed all residents refused showers, and that one resident could not be showered due to having a PICC (central venous) line.Resident interviews contradicted staff statements as follows:Interview with Resident R33 on December 29, 2025, at approximately 11:00 a.m. revealed the resident had not received a shower since admission to the facility three weeks prior.Interview with Resident R43 revealed the resident wanted a shower, had not refused, and stated she was never asked or offered a shower.Interview with Resident R174 revealed the resident wanted to be bathed; during the interview, a CNA was preparing to provide a bed bath.Interview with Resident R164 revealed the resident wanted a shower and stated she had never received one since admission.Interview with Resident R185 revealed the resident wished to receive a shower.Interview with Resident R180 revealed the resident wanted a shower and stated she was never asked or offered one. The resident reported washing herself with wipes due to not being provided shower assistance. 28 Pa. Code 201.20 (a)(5)(6)(b) Staff development 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of a facility document, interviews with residents and staff and review of clinical records, revealed that the facility failed to meet the standard of care for diabetes management and hypoglycemia monitoring in a timely manner for one of 11 residents reviewed. (Resident R164) Findings include: Review of facility policy titled Hypoglycemia Diabetic Management last reviewed May 2025 revealed the facility requires staff to quickly and safely respond to residents exhibiting signs or symptoms of hypoglycemia, to manage diabetes to prevent hypoglycemia, to monitor blood glucose per physician orders, and to ensure timely assessment, intervention, physician notification, and documentation of hypoglycemic episodes. Review of facilities policy titled Care Planning Process and Care Conference last revised March 19 2025 revealed the facility's policy requires the development and implementation of a comprehensive, resident-centered interdisciplinary plan of care for each resident, based on completed assessments and in compliance with federal and state regulations. A baseline care plan must be initiated upon admission and completed within 48 hours, addressing the residents' primary diagnosis, identified risks, and individual needs. The care plan serves as a working document that guides staff in delivering care consistently with professional standards. The interdisciplinary team (IDT)-including nursing, physician (as applicable), dietitian, social services, rehabilitation, nursing assistants, and the resident and/or resident representatives are responsible for care plan development, review, and revision. Care plans must include specific, measurable goals, interventions, responsible disciplines, and target dates, and must be updated with any change in condition. According to the American Diabetes Association (ADA) and the Centers for Disease Control and Prevention (CDC), hypoglycemia is generally defined as blood glucose level below 70 Mg dl. When blood sugar drops too low, individuals may experience symptoms as shakiness, sweating irritability, confusion, dizziness or lightheadedness, rapid heartbeat and blurred vision. If untreated hypoglycemia may progress to severe symptoms, including loss of consciousness, seizure, or coma which can be life-threatening. Initial treatment typically involves the immediate intake of fast acting carbohydrates, such as glucose tablets, juice or non diet sodas, followed by reassessment of blood glucose levels. In severe hypoglycemia, the ADA defines the condition as a medical emergency, particularly when the blood glucose levels fall below 54 MG Slash DL in these situations assistance from another person is required which may include administration of glucagon or activation of emergency medical services. While mild hypoglycemia may be managed by the individual with fast acting carbohydrates severe hypoglycemia requires urgent medical interventions both the ADA and the CDC stressed the importance of timely monitoring, reassessment, and individual lies care planning after hypoglycemic episodes to prevent reoccurrence and avoid serious harm. Review of the American Diabetes Association (ADA) standards of care 2025, section 14: Diabetes Care in Long-Term Care Settings, Diabetes care 2025;48(Suppl 1): S1-S3 state that episodes of hypoglycemia require prompt evaluation and individualized intervention and that the recurrent or severe hypoglycemia should trigger reassessment of the diabetes management plan to prevent further events. The ADA emphasizes that blood glucose monitoring, individualized treatment adjustments, dietary review, and ongoing risk assessments are integral parts of safe diabetes care. Review of The Centers for Disease Control and Prevention CDC Hypoglycemic Guidance-Immediate treatment and post episode monitoring to prevent recurrence. https://wwwcdc.gov/diabetes/treatment/treatment-low-blood-sugar-hypoglycemia.html recommends immediate treatment of hypoglycemia blood glucose less than 70MG per DL and frequent post episode monitoring and care plan review to identify contributing factors and reduce reoccurrence. Review of Resident R164's hospital discharge orders dated December 3, 2025, revealed that Resident R164's medication list with instructions to continue the following medications: one touch delica plus Lancet 33GAGE miscellaneous for type two diabetes mellitus with chronic kidney disease on chronic dialysis, unspecified whether long-term insulin use. With instructions one Lancet 4 times a day for diabetes management, which was not transferred to resident physician orders, indicating the hospital discharge recommendations for Accu-checks were not implemented upon admission. Review of Resident R164's admission Minimum Data Set (MDS -a federal mandated assessment tool for all residents) dated December 9, 2025, revealed that Resident R164 entered the facility on December 3, 2025 with diagnosis including Hypertension ( is a condition where blood pressure is consistently elevated above normal levels), renal failure ( a condition in which the kidneys lose the ability to filter waste and excess fluids from the blood effectively , diabetes mellitus ( is a chronic condition where the body either becomes resistant to insulin or doesn't produce enough insulin leading tear elevated blood sugar levels), seizure disorder(also known as epilepsy is a neurological condition characterized by recurrent unprovoked seizures), and anxiety(is a mental health condition characterized by excessive worry fear or nervousness often interfering with say the activities). The residents' medications include an antidepressant, anticoagulant, antibiotic, diuretic, and the anti-convulsant. Resident R164 receives dialysis. Further review of resident R 164 MDS revealed residents cognition assessed with a brief interview of mental status (BIMs) score of 14 indicating that the resident cognition is intact. Review of resident R164's care plan revealed this resident is at risk for complications from hemodialysis related to end stage renal disease-initiated December 4, 2025, with interventions to adjust medication schedule necessary on dialysis days, maintain enhanced barrier precautions, monitor permcath for signs of bleeding swelling or infection every shift in is needed monitor vital signs as ordered. Continued review of resident's care plan revealed a focus of nutrition, the resident at is at risk for alteration in nutrition hydration related to facility adjustment diabetes and stage renal disease and depression date December 4, 2025 with interventions of diet is ordered, encourage food and fluid, monitor for signs or symptoms of hyper or hypoglycemia, monitor PO (by mouth) intake, supplements as ordered. The goal was for Resident R164 will have no signs and symptoms of hyper or hypoglycemia through the next review date- December 4, 2025. Resident R 164 does not care planed for diabetes management, or hypoglycemia. Review of the Registered Dietitian's nutrition assessment dated [DATE], revealed that the resident was ordered a renal carbohydrate-controlled diet and had a good appetite, consuming approximately 75% of meals. However, there was no evidence of diabetic snack orders or coordinated dietary interventions related to blood glucose management, and no reassessment of nutritional needs following hypoglycemic episodes. R Review of Resident R164's nursing notes revealed that the resident experienced multiple documented hypoglycemic episodes: -December 17, 2025, the resident experienced a hypoglycemic with a documented blood sugar of 48 mg/dl episode requiring glucagon administration. -December 19, 2025, the resident's blood glucose was documented at 34 mg/dL following dialysis. -December 29, 2025, the resident experienced another hypoglycemic episode with a documented blood glucose of 44 mg/dL, which was associated with a fall. Continued review of resident's clinical records revealed there was no evidence of timely physician reassessment, modification of the diabetes management plan, or consistent escalation of monitoring until December 30, 2025, when hypoglycemia protocols, endocrinology consultation, and routine snack orders were initiated. Review of the resident's December 2025 Medication Administration Record (MAR) revealed inconsistent and incomplete documentation of blood glucose monitoring. Continue review of December 2025 MAR revealed that blood sugar checks were in place for specified periods. Nursing staff documented that blood sugars were checked without recording actual glucose values, and multiple required blood glucose readings were not recorded. An interview with Resident R1 conducted on December 29, 2025, revealed that the resident identified herself as a diabetic and reported that she was not receiving any snacks. The resident stated that her blood sugar levels continued to drop and that, despite these episodes, she was still not being provided snacks to help manage her blood glucose. A second interview with the resident conducted December 30, 2025, at 11:00 a.m. revealed continued concerns regarding lack of diabetes management. The resident stated that no one was taking care of her blood sugar monitoring and reported that she had passed out the night before due to low blood sugar. The resident further stated that she was still not receiving snacks at that time. Interview conducted on January 2, 2026, at 10:35 a.m., the resident stated that she had still not been offered any snacks. She reported experiencing multiple episodes of loss of consciousness and stated that she had fallen three times, recalling only waking up with staff around her. The resident stated she did not believe she was injured but described feeling scared and uncertain following the incidents. The resident further reported that she had not seen a physician and had not had any discussion regarding her diabetes or blood sugar management. Interview conducted on January 2, 2026, with the Medical Director, Employee E7, acknowledged that the resident experienced three documented hypoglycemic episodes and stated that while an isolated episode may not require increased monitoring, recurrent hypoglycemia warrants further evaluation and escalation of care. Employee R7 confirmed that consultation with endocrinology following repeated events was medically appropriate. Employee E7 further stated that dialysis patients are at increased risk for glucose variability and require careful coordination of monitoring, nutrition, and dialysis schedules. Phone interviews with the attending physician, Employee E8 on January 2, 2025, revealed acknowledgment of the resident's hypoglycemic episodes and confirmation that increased monitoring was ordered following recurrent events. The physician explained that hypoglycemia in dialysis patients is often related to nutritional intake and dialysis timing rather than medication use and emphasized the importance of dietary interventions and meal coordination. The physician acknowledged documentation gaps and indicated that additional documentation would be completed. Interviews with Licensed nurse manager, Employee E9 revealed delays in initiating blood glucose monitoring, and missed meals related to dialysis scheduling. The nurse manager acknowledged inconsistencies in pre- and post-dialysis documentation, gaps in communication, and failure to consistently ensure that diabetic residents received meals or snacks when leaving the facility for dialysis. These failures contributed to recurrent hypoglycemic episodes and delayed interventions. Continued interview revealed that typically when a resident enters the facility with a diagnosis of diabetes the physician orders include a batch order including accu checks (blood sugar monitoring). 28 Pa Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.10 (b)(c) Care Policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required licensure and certifications for three of three employees reviewed. (Employee E13, Employee E14, Employee E15)Findings include:Review of Facility contract with nursing staffing agency, titled Schedule A Statement of work ( SOW) #1 dated [DATE], under section 1. Services d. It is understood and agreed by Facility [nursing staffing agency] only refers candidates for consideration and that the hiring decisions and determinations of suitability, employment eligibility verification and conditions of employment are ultimately the responsibility of Facility. Review of Employee E13's personnel file revealed that Employee E13 was agency employee, hire date of [DATE], working as a Supervisor Registered Nurse. Review of facility investigation revealed on [DATE], it was reported to facility leadership that Employee E13's nursing license was suspended on [DATE]. Interview with Employee E2, Director of Nursing confirmed that upon checking the license verification system on [DATE], it was confirmed that Employee E13's registered nursing license was suspended on [DATE]. Further interview with Employee E2, Director of Nursing, confirmed that Employee E13 worked 19 shifts between [DATE] and [DATE] in the role of Supervisor Registered Nurse. Interview with Employee E2, Director of Nursing on [DATE] at 10:25am revealed that nurses and staff accepted to work in facility nursing staffing agency have all required documentation (license, background checks, etc) loaded into a portal for facility to review and if a nurse unknown to the facility then Director of Nursing will usually confirm license verification via the State Licensing online system. Interview with Employee E1, Nursing Home Administrator on [DATE] at 10:30am revealed that prior to referenced incident, employee licenses and certifications were audited annually as a part of the mock survey process. After referenced incident, facility started new policy for HR Director to maintain a file with a 3 month look ahead with license/ certification expiration dates. However, it did not include agency staff. There was no documented evidence that facility independently verified Employee E13's registered nursing license. Review of Employee E14's personnel file revealed that the employee was full-time employee, hire date of [DATE], working as a nursing Aide. Review of facility investigation revealed that Employee E14, nurse aide certification expired on [DATE]. Interview with Employee E1, Nursing Home Administrator on [DATE] at 10:30am confirmed that Employee E14 remained fulltime in facility between [DATE] and [DATE]. Review of Employee E15's personnel file revealed that the employee was full-time employee, hire date of February 7, 2024, working as a Nurse aide. Review of facility investigation revealed that Employee E15, nursing assistant certification expired on [DATE]. Interview with Employee E15, Nursing Home Administrator on [DATE] at 10:30am confirmed that Employee E15 remained fulltime in facility between [DATE] and [DATE]. 28 Pa. Code 201.19(7) Personnel records

Based on observation, review of facility policy and procedures and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to water cup distribution for three of 33 residents observed. (Resident R8, Resident R121 and Resident R18)Findings include: Review of Water Pitcher Pass/ cleaning review date April 2025, revealed that Styrofoam cups will be replaced nightly on 11-7 shift. Cups should be labeled with date of placement. Continued review revealed Nursing staff will fill water pitchers/Styrofoam cups with ice and fresh water placing them at bedside. Interview with Resident R8 on December 29, 2025, at 10:30am, revealed resident doesn't feel like she gets offered enough water and they always use the same cup and fill it at the bathroom sink. Observation of Resident R8's Styrofoam water cup on bedside table on December 29, 2025, at 10:30am, revealed that cup was labeled with a date of December 18, 2025, 11p-7a. Interview with Resident R121 on December 29, 2025, at 10:30am, revealed that cups get filled in the bathroom sink when requesting water and cups do not get replaced often. Observation of Resident R121's Styrofoam water cup on bedside table on December 29, 2025, at 10:35am, revealed that cup was labeled with a date of December 26, 2025, 11p-7a. Interview with Employee E12, Nursing Assistant on December 29, 2025, at 10:45am, confirmed findings and stated, I don't know what happened, I am agency, but I think cups are supposed to be changed every night shift. Interview with Resident R18 on December 29, 2025, at 10:55am, revealed concerns related to water cups filled in bathroom sink of shared resident bathroom and that resident was disgusted by this. 28 Pa Code 211.12 (d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, as well as interview with staff and residents, it was determined that facility did not ensure to honor residents' preferences related to fresh air breaks and activities for two of 33 residents reviewed (Resident R58 and Resident R16). Findings inclide: Review of facility policy 'Activity Programs,' reviewed on April 2025, indicates that activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.Further review of policy indicates that activities offered are based on the comprehensive resident-centered assessment and the interest and preferences of each resident. Interview with Resident R58 on Monday, December 29, 2025, at 11:45 am, revealed that the only residents who are accommodated with fresh air breaks are the ones who smoke. Further interview with R58 revealed that she is non-smoker, and when she attempts to bring up fresh air break times during resident council meetings, the staff who hold meeting do not address her preference. Interview with facility's activities director, employee E3, on Tuesday, December 30, 2025 at 3:00 pm, revealed that facility currently does not offer fresh air breaks to non-smoking residents' due to weather conditions. Review of Resident R16's clinical record revealed resident admitted to facility on February 27, 2020 with diagnosis of TBI (Traumatic Brain Injury), Major Depressive Disorder and Schizophrenia. Review of Resident R16's BIMS (Brief Interview for Mental Status) assessment dated [DATE], resident scored 11, indicating resident is moderately impaired. Interview with Resident R16 on December 29, 2025 at 12:00pm, We just don't get fresh air unless you are smoking. I feel locked up when I can't go outside, it's terrible. I want to go outside sometimes and they just don't let us. Further interview revealed that resident has expressed this on multiple occasions and no one listens. 28 Pa Code 211.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 10 records reviewed related to resident's behaviors (Resident R1).
Findings include:
Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses including, bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, post-traumatic stress disorder (a mental condition that's caused by an extremely stressful or terrifying event) and schizoaffective disorder (mental condition that combines schizophrenia and mood disorder).
Reviewed of social worker note for Resident R1 revealed that on January 24, 2025, at 8:40 a.m. fire alarm went off shortly after and resident was in the vicinity.
Further review revealed a clinical nurses note, dated January 27, 2025, at 9:34 p.m. revealed that resident pulled the fire alarm.
Further review revealed a note, dated February 11, 2025, 7:21 a.m. revealed that resident pulled fire alarm on another wing, police and fire came and talked to resident and supervisor.
Further record reviews for Resident's R1 care plan were not update with the behavior of pulling the fire alarm.
Interview with Director of Nursing, Employee E2, on February 19, 2025, at 10:30 a.m. confirmed that she just revised the care plan related to the resident's behaviors.
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations of the food and nutrition services department, interviews with staff, reviews of policies and procedures and the pest control operator's reports, it was determined that the main kitchen was not maintained and operated to ensure an effective pest control program.
Findings include:
Review of the policy titled kitchen cleaning dated December, 2024 revealed that it was the responsibility of the dietary staff to ensure that the main kitchen was clean and sanitary by adhering to a comprehensive cleaning schedule throughout the food and nutrition department.
Observations of the main kitchen in the presence of the director of dietary, Employee E5, at 9:30 a.m., on December 2, 2024 revealed the following:
The plumbing in the dish room area was not draining properly. Soiled water and food waste was over flowing onto the floor in the this section of the main kitchen. A dietary staff member was using a hand held plunger to try to unclog the sink that was adjacent to the dish machine.
The flooring throughout the dish room area contained a covering of a white substance resembling lime deposits. The dish machine, work tables and racks that were connected to the dish machine contained a white powdery film that resembled hard water and calcium deposit residue.
The ceiling tiles in the dish room area contained water damage. The ceiling tiles were brown stained and warped. The ceiling light fixture screens above the dish machine, contained a collection of dead insects. The wall area and ceiling tiles contained dried food debris.
The grouting was missing between the floor tiles in the dish room. The missing grouting provided food for common household pests to breed and live. The disrepair in the flooring was porous and not easily cleanable. There was an accummulation of dirt, food debris and moisture in the gaps on the flooring. The entire perimeter of the flooring and cove molding in the dishroom contained a build-up of dirt and discarded food particles.
The ceiling tiles and light screen covering above the hot food preparation area that was adjacent to the hood situated directly above the hot food equipment and cooking, contained a heavy accumulation of grease, dust and food splattering.
An industrial sized piece of food service equipment located in the hot food preparation area, called a braise or tilt skillet was not functioning for several months. It contained a build of grease, food debris and dust.
The perimeter of the flooring in the dry food storage area contained an accumulation of streaking and smudging along the perimeter of the flooring and walls with patches of mice droppings.
The ceiling light screens located in the dry food storage area were brown stained with water damage. The ceiling light screens also contained a large number of dead roaches.
The working mechanisms underneath the three compartment sink were not holding water regularly and a catch pan was placed below the piping to capture the leaking water.
The pest control operator's reports were reviewed for September, October and November, 2024 and revealed that the main kitchen of the food and nutrition department was targeted for common household pests (roaches and mice). The pest control operator was used various treatments and traps to combat the invaders.
28 PA. Code 201.14(a) Responsibility of licensee
28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management
28 PA. Code 205.13(b) Floors

Based on observations and interviews with residents, it was determined that the facility failed to maintain or enhance the dignity and respect for two of 33 residents reviewed (Resident R38 and R124).
Findings include:
During an interview with Resident R38 and R124 on December 4, 2024, at 3:40 p.m. the residents stated that when laundry labels their clothes with their names, they put it in places where it is visible when you are wearing them. Resident R38 stated they put my name on a collar of a shirt, in the front where you can see it when you are wearing it.
Resident R124 revealed the jacket she was wearing had a 2-inch belt and on the back of the belt in large letters was the resident's name.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29 (j )Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that a comprehensive assessment was completed accurately related to language and communication for one of 33 records reviewed (R417).
Findings include:
Review of clinical documentation revealed that Resident R417 was admitted to the facility on [DATE], with diagnoses of traumatic subdural hemorrhage (brain bleed caused by injury, which can damage the brain and result in lack of normal functioning), cerebral infarction (death of an area of brain tissue), and dementia (a degenerative neurological condition which results in impaired memory and judgement). Progress notes for the resident revealed that she was on comfort care, a protocol intended to keep a resident comfortable during end of life, but which is not hospice care.
Continued review of the documentation revealed that a Brief Interview for Mental Status (BIMS) assessment was completed for the resident on November 14, 2024. The resident scored a ten out of a possible 15, which indicated moderate impairment of cognitive function. This assessment also included a section titled Health literacy/Social isolation/Transportation/ Ethnicity/Race, in which it was stated that the resident's preferred language was Vietnamese.
Review of Resident R417's admission Assessment MDS, dated [DATE], revealed that in section V, Care Area Assessment, that the area Communication was triggered for review and care planning. Review of the accompanying Care Area Assessment worksheet for Communication revealed that under the triggered area Expressive communication, Speaks different language was not selected. No care plan for communication was found in the clinical record.
Review of physician notes dated December 4, 2024, at 11:25 a.m. stated, Pt is confused per interpreter service. A Clinical Nurses Note, dated December 1, 2024, at 10:35 p.m., stated, Resident is unable to make needs known.
Observations conducted on December 2, 2024, at 11:30 a.m. revealed that the resident was unable to speak with the surveyor in English and was responding in short words in another language, which the surveyor did not speak.
Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Resident R417 communicated primarily in Vietnamese, and that it should have been reflected in the Care Area Assessment that the resident spoke a different language.
28 Pa Code 211.12 (d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview with staff and residents and review of facility policy, it was determined that the facility did not develop a person-centered baseline care plan within 48 hours of a resident's admission related to language and communication for two residents, for a surgically wired jaw for one resident, and mental healthcare needs for one resident of 33 residents reviewed (Resident R158, R315, R417, R420).
Findings include:
Review of facility policy, Care Planning Process and Care Conference, revised July 3, 2023, revealed:
Staff shall interact with the residents in a way that accomodates the physical or sensory limitations of the residents, promotes communication and maintains dignity. The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. When encountering LEP individuals, staff members will conduct the initial language assessment and notify the staff person in charge of the language access program. The coordinator of the facility's language access program. The coordinator of the the facility's language access program is the Director of Social Services, or his/her designee as determined by the NHA. It is understood that providing meaningful access to services provided by the facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral Interpretation Services therefore include interpretation from The LEP resident's primary language back to English. Care plans should reflect the LEP services utilized and specific activity programs that are provided to the resident based on their preferences. Activity programs are designed to meet the interests of and support the physical, mental and psycho-social well beingof each resident as well as, encouraging both independence and community iinteraction.
An interdisciplinary baseline care plan will be initiated upon admission by the admitting nurse and completed within 48 hours. A copy of the baseline care plan will be reviewed with and provided to the resident/patient and/or resident representative, upon admission (within 48 hours). Facility will maintain evidence that the baseline care plan was provided (ex: nursing enters an admission progress note indicating resident admitted , assessments completed, introduced to surroundings and a copy of the baseline care plan was reviewed with resident and left at the bedside. RP called to notify of resident's arrival and baseline care plan was reviewed with RP). Include such initial needs/problems such as ADL's, falls, skin tears, risk for skin breakdown, nutritional status, behaviors, pacemaker, anticoagulants, psychotropic medication use, etc. Include a care plan related to the resident's primary diagnosis.
Resident R158 was admitted to the facility on [DATE] with the following diagnoses: encephalopathy (brain disease that alters brain function or structure); severe protein calorie malnutrition (critical condition where a personis severelydeficient in both protein and calories, leading to significant muscle wasting, loss body fat, and impaired immune function. Diabetes Mellitis type II (condition in which body has trouble controlling blood sugar and using it for energy.) and cerebral infarction due to embolism an ischemic stroke).
Review of Resident R158's MDS (Federally mandated resident assessment and care screening) dated November 13, 2024, revealed that English is the primary language of Resident R158.
Review of Resident R158s baseline care plan revealed no evidence of language barrier or communication challenges related to English as a second language and Vietnamese as the primary language. Resident R158's care plan did not reflect the LEP services utilized and specific activity programs that are provided to Resident R158 based on her preferences.
Interview on December 3, 2024 at 10:42 a.m. with Employee E3, unit manager, revealed that Resident 158 understands some English and speaks Vietnamese. We have consistent staffing here and the resident has a good rapport with her nurse aide. For almost all of our residents (on the memory care unit). we anticipate their needs. We have used the interpreter hotline at times, but not often. Usually we can anticipate her needs.
Employee E13, Resident R158's nurse aide was unavailable for interview.
Resident R158 was unable to participate in an interview with surveyor.
Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Residenst R417 and R158 communicated primarily in Vietnamese, and that it should have been reflected in the Care Area Assessment that the resident spoke a different language.
Review of Resident R315's Admissions Minimum Data Set, dated [DATE]. 2024, revealed the resident was alert and oriented, able to make needs know, diagnosed with multiple fractures, and impaired to both sides of her upper and lower body.
Nursing note dated November 14, 2024, stated Resident R315 was a pedestrian in a motor vehicle accident and sustain multiple fractures and lacerations to her internal organs. The resident's jaw was wired closed and was ordered a clear liquid diet instructing to be fed with a syringe and a staff member present at all times with meals.
Review of Resident 315's care plan revealed the resident was at risk of aspiration and instructed to monitor for signs and symptoms of aspiration. Further review of the care plan failed to develop a plan of care to include removing the wires from the jaw in an emergency.
Interview with the Director of Nursing indicated pliers were available at the resident's bedside in case the wires needed to be removed but confirmed the intervention was not included in the resident's plan of care.
Review of clinical documentation revealed that Resident R417 was admitted to the facility on [DATE], with diagnoses of traumatic subdural hemorrhage (brain bleed caused by injury, which can damage the brain and result in lack of normal functioning), cerebral infarction (death of an area of brain tissue), and dementia (a degenerative neurological condition which results in impaired memory and judgement). Progress notes for the resident revealed that she was on comfort care, (a protocol intended to keep a resident comfortable during end of life, but which is not hospice care).
Review of Resident R417's MDS completed November 14, 2024, indicated a Brief Interview for Mental Status (BIMS) assessment with a score of ten -moderate impairment of cognitive function. This assessment also included a section titled Health literacy/Social isolation/Transportation/ Ethnicity/Race in which it was stated that the resident's preferred language was Vietnamese.
Review of resident R417's admission Assessment MDS, dated [DATE], revealed that in section V, Care Area Assessment, that the area Communication was triggered for review and care planning. No care plan for communication was found in the clinical record.
Review of physician notes dated December 4, 2024, at 11:25 a.m. stated, Pt (patient) is confused per interpreter service. A Clinical Nurses Note, dated December 1, 2024, at 10:35 p.m., stated, Resident is unable to make needs known.
Observations conducted on December 2, 2024, at 11:30 a.m. revealed that the resident was unable to speak with the surveyor in English and was responding in short words in another language, which the surveyor did not speak.
Interview with Employee E1, the Nursing Home Administrator, and E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Resident R417 communicated primarily in Vietnamese, and that a baseline care plan for communication should have been developed and was not.
Review of documentation for Resident R420 revealed that he was admitted to the facility with diagnoses,of suicidal ideations, and bipolar disorder (a mental health condition consisting of extreme highs and lows in mood and affect, which can impact decision making and behaviors).
Review of the care plan for the resident revealed that no care plan was developed related to his specific mental health needs related to suicidal ideation and bipolar disorder.
Observation of Resident R420 on December 3, 2024, at 1:03 p.m. revealed that the resident had a flat affect and appeared withdrawn.
Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that a baseline care plan for the specific mental health needs should have been developed and was not.
28 Pa. Code 211.5(f)(viii) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, review of clinical records, and interview with resident and staff, it was determined that the facility failed to develop and implement comprehensive, person-centered care plans to address resident care needs related to a diagnosis of anemia and psychotropic medications for one of 33 resident records reviewed (Resident R314).
Findings include:
Resident R314 was admitted to the facility on [DATE], diagnosed with anemia (not enough healthy red blood cells resulting in a reduced ability of the blood to carry oxygen to the body).
Review of Resident R314's physician note, dated November 20, 2024, referenced the resident's critical hematology report dated November 15, 2024. The same note stated to monitor Resident R314's hematocrit (present of red blood cells in the blood) and hemoglobin (Hgb transports oxygen and carbon dioxide) relating to the resident's diagnosis of anemia and stated to consider Transfer for (blood) transfusion if Hg drops <7.0, and to monitor for signs and symptoms of fatigue, impact on therapy, monitor for oxygen use, check pulse ox as needed prior to and during therapy.
Further review of Resident R314's clinical record revealed the facility failed to develop a care plan for the resident's diagnosis of anemia.
8 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(3) Nursing services.
28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for tube feeding management, for one of 33 residents reviewed (Resident R63).
Findings include:
Review of Resident R63's clinical record revealed that the resident was admitted in the facility on February 12, 2024. Resident R32's diagnoses included Protein Calorie Malnutrition ( condition synonymous with starvation, resulting when the body's needs for protein, energy, or both cannot be met by diet), and Oropharyngeal Phase Dysphagia (swallowing problems occurring in the mouth and/or the throat. These swallowing problems most commonly result from impaired muscle function, sensory changes, or growths and obstructions in the mouth or throat).
Review of physician order for Resident R63, dated April 1, 2024, indicated an order to cleanse area around feeding tube with soap and water and gently pat dry, daily and as needed; clean, dry drain sponge may be placed if needed; every day- shift and as needed.
Review of physician order for Resident R63, dated July 22, 2024, indicated an order for Controlled Carb/Renal Diet: Mechanical Soft Texture, Thin consistency.
On December 2, 2024, at 12:34 p.m., review of the care plan of R63, revealed that it was not updated, or revised, to reflect the goal and interventions with the ordered diet and peg tube site care. At the time of the findings, interview with the charge nurse, a Registered Nurse, Employee E6, confirmed the same.
28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, staff and resident interviews, and review of clinical records, it was determined the facility failed to provide the necessary services to maintain adequate grooming and hygiene for one of 33 sampled residents (Resident R315).
Findings include:
Review of Resident R315's Admissions Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 20. 2024, revealed the resident was alert and oriented, able to make needs know, and diagnosed with fractures and malnutrition, with impairments to both sides of her upper and lower body. The same MDS indicated the resident was dependent on staff for all activities of daily needs and when asked it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath.
Interview with Resident R315 on December 4, 2024, at 11:00 a.m. stated that she was never offered a shower since she's been at the facility. I only get bed bath and I would really like a shower.
Interview with Resident R351's Nursing Aide, Employee E3 on December 4, 2024, at 11:20 a.m. confirmed the staff only gives her bed baths because it might be too much for the resident.
Review of Resident 351's physician orders revealed the resident's shower/bath days were every Tuesday and Friday and care planned for needing one staff member to assist with bathing/showering. Further review of the resident's clinical records did not reveal restrictions for showering.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of care and services, review of clinical record and review of facility policy and interviews with staff and residents, it was determined that the nursing staff failed to obtain and schedule examinations with a specialist as indicated by the physician and to ensure that a medication was administered during the time period prescribed by the physician for two of 47 residents reviewed. (Resident R16 and Resident R315)
Findings include:
A review of the facility policy titled verbal and telephone physician's orders dated May, 2024 revealed that it was the policy of the facility to secure physican's orders for the care and services for the residents. The physician's orders for care and services were required to be dated and signed accordingly and entered into the resident's medical record.
The policy also indicated that an order for medical or therapeutic measures and medications or treatments were to be given to a registered or licensed nurse. The registered or licensed nurse were required to obtain a medical diagnosis or reason from the physician for the care, treatment or medication being used for the residents.
The policy also said that any unclear or incomplete physician's orders for care, treatment or medications were to be clarified by the registered or licensed nurse. The policy indicated that it was the responsibility of the registered or licensed nurse to verify with the physician any pending consultation or specialist appointments and recommendations or results of testing completed by a specialists.
Observations of Resident R16 at 10:30 a.m. on December 2, 2024 with Licensed nurse, Employee E4 revealed that the resident was reporting that she preferred to lay in a supine position because she was dizzy sitting up or moving side to side. The licensed nurse, Employee E4 reported at 11:00 a.m., on December 2, 2024 that Resident R16 had a diagnosis of vertigo (a sudden internal or external spinning sensation often triggered by moving the head).
Clinical record review revealed a quarterly comprehensive assessment (MDS- an assessment of care needs) dated October 31, 2024 for Resident R16 indicated that this resident was cognitively intact and had a diagnosis of cerebral palsy (a movement disorder affecting muscle tone, lack of balance and muscle coordination with stiff or floppy muscle characteristics).
Interview with Resident R16 at 10:45 a.m., on December 2, 2024 revealed that the resident has not been sitting up very long or getting out of bed into a chair; because of her dizziness. The resident also reported that an orthotic device for her neck or head was not used as adapted equipment for her symptoms of dizziness.
Clinical record review revealed that on April 30, 2024, the nurse practitioner assessed and documented that the nursing staff were to administer Resident R16 Meclizine (a medication for motion sickness and vertigo) 12.5 milligrams as needed for vertigo.
Clinical record review revealed the care planned by the nurse practitioner on April 30, 2024 was for the registered or licensed nursing staff to schedule an ear, nose and throat specialist examination for Resident R16 to evaluate the vertigo. Also for the resident to be evaluated by a neurologist to determine the causes of the vertigo symptoms.
Continue review of Resident R16's clinical notes dated April 30, 2024 revealed for nursing and physical therapy staff, to continue with active range of motion and passive range of motion exercises twice a day for Resident R16.
Interview with the licensed practical nurse, Employee E4 and the licensed occupational therapist, Employee E6 at 10:00 a.m., on December 3, 2024 confirmed that there was no ENT (ear, nose or throat) specialist examination ordered or completed for Resident R16. Further interview with the licensed nurse and licensed occupational therapist on December 3, 2024 confirmed that there was no physican's order obtained on April 30, 2024, for Resident R16 to be examined by a neurologist to determine the possible cause of her symptoms of frequent dizziness.
The lack of obtaining physician's orders by the licensed nursing staff for consultations with the ENT specialist and the neurologist (a physician who was trained in diagnosing and treating diseases of the brain, spinal cord and nerves) was confirmed by the Director of Nursing at 1:00 p.m., on December 4, 2024.
Review of the facility policy Medication Administration revised September 2023 states, Medications, both prescription and non-prescription shall be administered under the orders of the attending physician.
Review of Resident R315's clinical records revealed the resident was admitted on [DATE], diagnosed with multiple fractures and lacerations to her internal organs from a motor vehicle accident.
During an interview with Resident R315 on December 4, 2024, at 10:30 a.m. the surveyor observed a bottle of of Chlorhexidine Gluconate (an oral antimicrobial) next to the resident, sitting on the tray table. The resident indicated that she uses the mouth rinse after meals.
Review of Resident 315's physician orders revealed Chlorhexidine Gluconate was initially ordered for fourteen days on November 14, 2024, and was discontinued on November 28, 2024.
The above was confirmed with the Director of Nursing on December 4, 2024, at 1:30 p. that the oral rinse was discontinued.
28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services
28 PA. Code 211.10(a)(c)(d) Resident care policies
28 PA. Code 211.5(f)(i)(ii)(iii)(vii)(viii)(ix) Medical records

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R4, and R77).
Findings include:
On December 3, 2024, 9:39 a.m., observed that Employee E7, a Registered Nurse, administered to Resident R77, the medicine, Aspirin 81 mg, chewable tablet, one tablet by mouth; when asked the Licensed Nurse to double check the medicine, the nurse stated it was Aspirin 81 mg, chewable tablet.
Review of physician order for Resident R77, revealed an order, dated September 28, 2020, to administer Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG (Aspirin), give 1 tablet by mouth one time a day.
Review of literature revealed that Aspirin comes in enteric-coated and non-enteric (regular) forms. Regular Aspirin is absorbed in the stomach, while Enteric-Coated aspirin is absorbed in the small intestine.
At the time of the observation, interview with Registered Nurse, Employee E7, confirmed the above findings.
On December 3, 2024, 9:49 a.m., observed that Employee E7, administered to Resident R4, the medicine, Aspirin 81 mg, chewable tablet, one tablet by mouth; when asked Registered Nurse, Employee E7 to double check the medicine, the nurse stated it was Aspirin 81 mg, Chewable tablet.
Review of physician order for Resident R4, revealed an order, dated August 18, 2023, to administer Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 MG (Aspirin), Give 1 tablet by mouth in the morning for CVA (Cerebrovascular Accident, which is the medical term for a stroke).
At the time of the observation, interview with Registered Nurse, Employee E7, confirmed the above findings.
The facility incurred a medication error rate of 5.7%.
Pa Code:211.12(d)(1)(2)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews with staff, and review of facility policy and procedures, it was determined that the facility failed to ensure that one out of eight residents reviewed were monitored for acceptable parameters of weight. (Resident R5)
Findings Include:
Review of facility policy titled, Weight and Height Assessment and Interventions with a revision date on March 18, 2024 states, Policy: Purposes of this procedure are to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a height in order to determine the ideal weight of the resident. The Facility will ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance are maintained, unless the resident's clinical condition demonstrates that is not possible or resident preferences indicate otherwise; The nursing staff and the Dietician will coordinate care to prevent, monitor, and intervene for undesirable weight loss/gain for our residents.
Further review of the facility policy states, 4. Any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with licensed nurse confirming reweigh. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. Attending physician, resident/resident representative will be notified of unplanned significant weight changes as described below.
Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; cerebral infraction, sepsis, diverticulitis, elevated blood cell count, gastrostomy malfunction, dementia, end stage renal disease, adult failure to thrive, and depression.
Review of Resident R5's physician orders revealed an order from June 13, 2024 stating, Record post-dialysis (dry) weight in chart upon return from dialysis. The order was to be started on June 14, 2024 and weights should have been recorded Monday, Wednesday, and Friday.
Review of Resident R5's Medication Administration record for the month of August 2024 revealed no post-dialysis weight recorded for August 2, 2024 or August 21, 2024.
Review of Resident R5's Medication Administration record for the month of September 2024 revealed only two weights recorded: September 3, 2024-129 pounds and September 4, 2024-129 pounds.
Review of Resident R5's Weight Summary record on September 5, 2024 at 10:15 a.m. revealed the following weights;
August 30, 2024- 129 pounds
August 16, 2024- 132.7 pounds
August 9, 2024- 136 pounds
August 4, 2024- 137 pounds
August 2, 2024- 137 pounds
July 22, 2024- 137.5 pounds
July 18, 2024- 137.5 pounds
July 7, 2024- 155 pounds
July 6, 2024- 155.1 pounds
July 5, 2024- 155.1 pounds
July 3, 2024- 155.1 pounds
July 1, 2024- 155.1 pounds
June 28, 2024- 155.2 pounds
June 26, 2024- 155.4 pounds
June 21, 2024- 155.6 pounds
June 19, 2024- 155.4 pounds
June 17, 2024- 155.4 pounds
June 13, 2024- 155.4 pounds
Review of Nutrition/Dietary note on July 19, 2024 states, readmission: Returns s/p hospital stay, PMHx includes CVA, OA and HTN. Currently weighs 138# indicating -17# weight loss since returning, will continue to monitor admission weights. Body Mass Index indicating underweight, slow weight gain desirable. Enteral feeding ordered as Nepro 60ml x 20 hrs providing 1200ml TV, 2124kcal, 97g PRO and 872ml H2O. Flush ordered at 250ml q 4 hrs, providing an additional 1500ml H2O. Enteral orders meet estimated needs for weight gain. Receives mechanical soft, thin liquid trays in addition to enteral feed. No skin breakdown or edema noted upon return. Continue current POC, encourage meal acceptance, monitor for s/sx of aspiration, will follow prn. Plan to wean off enteral feed as intakes improve/stabilize.
Further review of resident clinical record shows no indication of the resident having a mechanical soft, thin liquid tray in addition to enteral feed. Review also revealed there was no indication of discontinuation of mechanical soft, thin liquid trays. Resident R5's record only showed resident as NPO (Nothing by mouth) while at the facility.
Interview with the facility dietician Employee E3 held on September 5, 2024 at 11:47 a.m. revealed the dietician stated that the resident arrived at the facility NPO (Nothing by mouth). When asked if the dietician had been monitoring Resident R5's weights he stated that he monitors all weights daily and for dialysis residents, the dialysis center keeps their own set of weights, and he is sent the weights weekly by e-mail from the dialysis dietician. Employee E3 stated that he had some confusion on if the licensed nurse at the facility should be completing a post-dialysis weight when the resident arrives back to the facility. When asked if he provided intervention for Resident R5's significant weight loss he stated, I would have to look, I'm not familiar, I would have to look to see if the first weight was a one-time weight or if he was re-weighed to establish a baseline weight. I usually wait to see the first few weights before getting a baseline weight. When asked about the facilities weight policy the dietician stated weights should be completed on admission, 24 hours later, and then weekly for 3 weeks.
Review of the facility Matrix for Resident R5 did not show the resident triggering for significant weight loss.
The dietician provided weights from the dialysis dietician at 1:15 p.m. for Resident R5 that showed the following post dialysis weights;
August 9, 2024- 71kg equal to 156.52 pounds
August 16, 2024- 70.4kg equal to 155.20 pounds
August 21, 2024- 70kg equal to 154.32 pounds
August 23, 2024-70.5kg equal to 155.42 pounds
August 28, 2024-72.3kg equal to 159.39 pounds
There was no post-dialysis weights recorded for Resident R5 for August 12, 14, 19, 26, and 30, 2024.
The dietician explained that based on the weights provided by the dialysis dietician the resident has a stable weight since admission. At this time the surveyor requested that Resident R5 be weighed today to confirm the higher weight. At 1:25 p.m. Resident R5 was brought to the scale by nurse aide Employee E6. Also present for the weight was facility dietician Employee E3. Resident R5 was not able to stand on the scale with assistance from nurse aide Employee E6 therefore he was weighed in his geri-chair. In the geri-chair Resident R5's weight was 208.8 pounds. The nurse aide Employee E6 weighed the geri-chair empty and it weighed 73 pounds. After calculation is was determined that Resident R5's current weight was 135.8 pounds. Facility dietician Employee E3 confirmed the weights sent electronically from the dialysis dietician are inconsistent and inaccurate.
Review of Resident R5's Weight Summary record on September 5, 2024 at 2:00 p.m. revealed there were additional weights added to the residetn's clinical record today by licensed nurse Employee E7 with the following weights;
August 7, 2024- 117 pounds
July 29, 2024- 114 pounds
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. 211.6(a) Dietary services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two residents reviewed. (Residents R2 and R5)
Findings Include:
Review of the facility policy titled, Dialysis Management (Hemodialysis) with a revision date of March 28, 2024 revealed, It is policy of the facility to ensure that residents who require outpatient hemodialysis treatment have appropriate arrangements made by the facility with an outpatient treatment center in order to provide such services as directed by the physician. Further review of the policy states, If Dialysis is provided at off-site Dialysis Center: 5. Develop a resident binder/folder to send to dialysis with the resident. Communication form is placed in the binder after completion of the pre dialysis assessment. 6. Facility to complete Pre-dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and facility. 7. Dialysis center personnel to complete Dialysis communication form and return to facility. Dialysis Center may provide HER documentation vs manual documentation of treatment on communication form. 8. Upon return from Dialysis Center, review information provided on Dialysis communication form/HER. Communicate and address as appropriate. 9. Facility to complete post-dialysis information/date and place in resident's medical record.
Review of Resident R2's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Morbid obesity, end stage renal disease, dependence on renal dialysis, muscle weakness, heart failure and cognitive communication deficit.
Review of Resident R5's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: elevated blood cell count, acute embolism and thrombosis, depression, dementia, chronic kidney disease, metabolic encephalopathy, spondylosis, cardiomyopathy, hyperparathyroidism, and hepatomegaly.
Review of Resident R2's dialysis communication records on September 5, 2024 at 11:18 a.m. revealed the for the months of July, August, and September 2024 revealed the communication records were incomplete. For the three months reviewed the dialysis book was missing a communication record form for the following dates: September 2, September 4, August 30, August 28, August 23, August 21, August 19, August 16, August 12, August 9, August 7, August 5, August 2, July 31, July 29, July 26, July 22, July 10, July 5, and July 1.
Interview with the licensed nurse Employee E4 on the unit at 11:22 a.m. revealed any communication records completed should have been placed in the binder for both Resident R2 and Resident R5. For the three months reviewed the dialysis book was missing a communication record form for the following dates: July 1, July 8, July 10, July 12, July 15, July 17, July 26, August 5, August 9, August 12, August 14, August 19, August 21, August 26, August 28, August 30, September 2, and September 4.
Review of Resident R5's of the dialysis communication records on September 5, 2024 at 11:18 a.m. revealed the for the months of July, August, and September 2024 revealed the communication records were incomplete.
Interview with the Director of Nursing Employee E2 at 2:07 p.m. confirmed the above findings and stated there were no other communication records found for Resident R2 or Resident R5.
28 Pa Code 211.5(f)(ix) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to identify a bed against the wall and an abdominal binder as a possible restraint and failed to assess the functional status of the resident to determine the use of the restraint for one of eight residents reviewed. (Resident R5)
Findings Include:
Review of facility policy titled Restraints (Physical) with a revision date of May 5, 2023 states, Policy: The resident has a right to be treated with respect and dignity, including: The right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Further review of the policy revealed, Procedure: 1. Complete a physical restraint assessment if resident is utilizing a restraint or there is potential that device may be a restraint, i.e. Geri chair, rock n go chair. Identify alternatives used prior to the initiation of the restraint. The restraint assessment will be completed upon admission/readmission, quarterly, annually, with a significant change, and initiation of or discontinuance of a restraint. 2. Obtain informed consent for physical restraint use identifying risks and benefits of its use. 5. A physical restraint will be removed at least 10 minutes out of every 2 hours during the normal waking hours to allow the resident an opportunity to move and exercise. Except during the usual sleeping hours, the resident's position will be changed every 2 hours if a device is in place. During sleeping hours, the position will be changed as indicated by the resident's needs. 6. The facility will document the use of a physical restraint and the release of the restraint; documentation can occur at the end of the shift indicating the restraints were released for ten minutes every two hours, I.e. on the MAR/TAR.
Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral infraction (stroke), anxiety, dementia (progressive degenerative disease of the brain), end stage renal disease, spondylosis (abnormal wear on the cartilage and bones of the neck)
Review of Resident R5's clinical record revealed a physician order with a start date of July 18, 2024 for Abdominal Binder remove for care and skin checks every shift.
Observation of Resident R5 on September 5, 2024 at 11:15 a.m. with the licensed nurse Employee E4 revealed the resident did not currently have the abdominal binder on. The licensed nurse stated the binder was in the laundry. The laundry room was checked at 12:11 p.m. and laundry staff were able to locate two abdominal binders for Resident R5 which were clean and ready to be sent back up to the unit for use.
Observation of Resident R5's room at 1:01 p.m. revealed the resident's bed was placed with the left side up against the wall. There was one fall mat in the room which was leaning up against the wall due to the floor being wet from mopping.
Review of Resident R5's current care plan revealed that there was no care plan developed for the resident's bed to be against the wall and for the abdominal binder. Further review of the resident's clinical record revealed there was no restraint assessment completed for the bed against the wall or the abdominal binder.
Interview held with the Director of Nursing Employee E2 on September 5, 2024 at 1:10 p.m. confirmed the above findings that the resident had no been assessed for the physical restraints the facility has in place including the abdominal binder and the bed against the wall.
28 Pa. Code 211.8(e)(f) Use of Restraints.
28 Pa. Code 211.10(d) Resident Care Policies.
28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on staff interview, observation, and review of facility documentation, it was determined that the facility failed to ensure a safe comfortable homelike environment relating to daily cleaning and pest control for two of 15 residents reviewed. (Resident R12 and R15)
Findings:
Review of policy titled pest control last revised November 11, 2019, revealed that it is the responsibility of the maintenance department to coordinate the control of pest with a company engaged in the business of providing Pest Control Services. The pest control company will provide the control of roaches, ants, rodents, spiders, and other insects that may be harmful to humans, equipment, supplies, or documents through direct contact or contamination. All service technicians shall strictly adhere to all applicable policies and any specific instructions given by environmental/ facility directors. Od particular importance are rules or restrictions regarding contamination of hospital supplies and access to restricted areas.
Interview with Resident R12 on May 7, 2024, at 11:22 a.m. revealed disappointment and discomfort with the facility cleanliness regarding insect infestation. Resident R 12 stated that there were bugs crawling all over his room. Resident R12 directed the surveyor to perimeter of the room where four traps can be viewed. Resident R12 revealed that the facility has been aware, and exterminator had been there a week prior at which time he left the traps and gave extra traps to the resident and has not returned. Resident R12 states that housecleaning come daily but the traps have been left.
Interview with Resident R15 on May 7, 2024, at 11:22 a.m. revealed that the resident could not leave the room without assistance. The resident confirmed that the insects are all over the room,and that she had witnessed the bugs migrating at night.
Observation of resident R 12 and R15's room revealed four sticky traps, glue boards containing an abundant amount of large black bugs found on each trap. The observation was confirmed by facility maintenance director Employee E5, who could not explain why the traps containing bugs have been left in various areas of the resident's room.
28 Pa. Code 201.18(b)(1) Management

Based on observation, review of facility policies, and interview with resident and staff, it was determined that the facility failed to ensure one of 14 residents reviewed received assistance with toileting and personal hygiene in a timely manner. (Resident R2)
Findings include:
Review of facility policy titled ADL care Personal Care/ Grooming-Shaving reviewed March 12, 2024, revealed the facility will promote care for residents that maintain or enhance their dignity and respect. Report other information in accordance with facility policy and professional standards of practice. ADL documentation will be completed by the certified nursing assistant that provided the assistance by the end of each shift. The licensed nurse will be made aware of the refusal.
Review of Resident R2's care plan-initiated December 13, 2022, revealed that resident was incontinent of bowel and bladder due to cognitive impairment with goals of having elimination and skin care met with dignity and respect. An intervention of this plan included for the resident to be check every two hours and provided incontinence care as needed.
Review of Resident R2's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated March 11, 2024 revealed that the resident requested set up and clean up assistance for toileting and and personal hygiene.
Observation of Resident R2 on May 8, 2024, at 10:50 a.m. revealed Resident R2 was observed lying in bed, the sheets were visibly soiled and stained with a strong odor of urine. Resident R2 was positioned to the side of the bed, and it was observed that his clothing was stained as well. Observation of the resident at the above time with Nurse aide, Employee E9 confirmed the bedding was soiled stating the resident has accidents at night. Employee E9 admitted that she had not provided morning care to Resident R2 yet.
Further observation of Resident R2 revealed that the resident had disheveled hair and unkept facial hair. During interview at the time of the observation Resident R2 admitted that he would like to have his beard shaved.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to provide residents with respiratory therapy per physician orders for two of two residents reviewed (Residents R40 and R2).
Findings Include:
Review of facility policy BIPAP (bilevel positive airway pressure - a type of ventilator that helps with breathing by delivering different levels of air pressure to the lungs) and CPAP (continuous positive airway pressure) Policy and Procedure revised May 2021, revealed BIPAP and CPAP is administered by licensed nurses with a physician's order. BIPAP and CPAP may be prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation.
Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had a diagnosis of obstructive sleep apnea (a condition when your breathing is interrupted or stopped during sleep).
Review of Resident R40's comprehensive care plan revised January 24, 2024, revealed the resident had altered respiratory status/difficulty breathing related to sleep apnea. Interventions dated January 19, 2024, included use of BIPAP.
Review of Resident R40's clinical record revealed a physician order dated February 1, 2024, to apply BIPAP nightly and with naps.
Review of Resident R2's annual MDS dated [DATE], revealed the resident was cognitively intact and had a diagnosis of chronic respiratory failure (a condition where the lungs cannot supply enough oxygen or remove enough carbon dioxide from the blood) with hypoxia (below-normal level of oxygen in your blood).
Review of Resident R2's clinical record revealed a physician order dated February 1, 2024, to apply BIPAP at bedtime and remove in the morning.
Interview on February 25, 2024, at 11:39 a.m. with alert and oriented Resident R27 revealed nursing staff did not apply BIPAP for roommate Resident R2.
Interview on February 25, 2024, at 11:46 a.m. with Licensed Nurse, Employee E14, confirmed Resident R2 reported nursing staff did not apply BIPAP at night on February 24, 2024, and that this was not the first time that has happened.
Interview on February 25, 2024, at 12:04 p.m. with Resident R2 revealed the nurse did not apply BIPAP at night on February 24, 2024. Resident R2 reported using the call bell but the nurse never came.
Interview on February 26, 2024, at 1:30 p.m. with Resident R40 revealed nursing staff did not apply BIPAP machine at night on February 25, 2024.
Interview and observations on February 26, 2024, at 1:36 p.m. with the Director of Nursing, Employee E2, revealed the usage log history on Resident R2's and R40's BIPAP machines confirmed the residents did not have BIPAPs applied on alleged dates.
28 Pa. Code 211.10 (d) Resident Care Policies
28 Pa. Code 211.12 (c)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, observations, and staff and resident interviews it was determined that the facility failed provide food items consistent with the prescribed diet order for one of five residents observed during dining (Resident R40).
Findings Include:
Review of facility diet guide sheet revealed Sunday lunch offerings on February 25, 2024, was breaded chicken, beef chopped steak, baked fish, mashed potatoes, steamed rice, yellow squash, carrots, and tropical fruit. Per the diet guide sheet, a resident on a Renal (a specialized diet for people with kidney problems)/CCD (carbohydrate controlled) diet should receive steamed rice instead of mashed potatoes.
Review of Resident R40's physician orders revealed the resident was ordered a Carbohydrate Controlled/Renal diet dated January 23, 2024.
Review of Resident R40's nutrition assessment dated [DATE], confirmed to continue CCD/Renal diet as ordered by the physician.
Observations on February 25, 2024, at 12:46 p.m. revealed Resident R40's meal ticket confirmed the resident was ordered a Renal, CCD Diet. Further review of the meal ticket indicated the resident was to receive 4 ounces of steamed rice. Further observations of Resident R40's lunch time meal tray revealed the resident was served mashed potatoes.
Interview on February 25, 2024, at 1:00 p.m. with Registered Nurse, Employee E5, confirmed Resident R40 received mashed potatoes instead of rice.
28 Pa. Code 211.6 (a) Dietary Services

Based on observations and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly.
Findings Include:
An initial tour of the Food Service Department was conducted on February 25, 2024, at 9:15 a.m. with the Assistant Food Service Director, Employee E4, which revealed the following:
Observations of the trash area revealed a large trash compactor. Continued observations revealed a significant build-up of trash, food, and debris surrounding and along the perimeter of the trash compactor.
Interview with the Assistant Food Service Director, Employee E4, on February 24, 2024, at 9:20 a.m. confirmed the observations.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed to ensure a dependent resident received assistance with activities of daily living for one of 34 residents reviewed (Resident R40).
Findings Include:
Review of facility policy ADL (Activities of Daily Living) Care - Supporting Resident revised 01/31/2023 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Review of Resident R40's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 25, 2024, revealed the resident was cognitively intact and had diagnoses of muscle weakness and abnormalities of gait and mobility.
Continued review of the MDS revealed Resident R40 had impairment in functional range of motion to the lower extremities and was dependent on staff for transfers to and from bed, rolling left and right, toileting hygiene, and lower body dressing. Resident R40 required supervision/touching assistance with personal hygiene.
Review of Resident R40's comprehensive care plan dated February 23, 2024, revealed the resident was at risk for decline in functional mobility, strength, balance, and endurance.
Interview and observation on February 26, 2024, at 1:03 p.m. with Resident R40 revealed the resident was still in bed and the resident reported to not have received morning care yet.
Interview on February 26, 2024, at 1:45 p.m. with nurse aide, Employee E3, confirmed this employee did not assist Resident R40 with morning care. Further interview revealed that the staff member assigned to provide care for Resident R40 was late and therefore did not provide care in a timely manner.
Interview on February 27, 2024, at 12:45 p.m. with Resident R40 revealed on February 26, 2024, the resident wanted to be assisted out of bed and into the chair to have dinner. Further interview revealed staff did not assist resident out of bed until after dinner at 8:15 p.m. and subsequently was not put back into bed until 11:30 p.m.
Review of Resident R40's clinical record revealed a nursing note dated February 26, 2024, at 6:00 p.m. by Registered Nurse, Employee E6, that confirmed staff failed to assist the resident out of bed in a timely manner. Registered Nurse, Employee E6, stated in the nursing note that R40 kept ringing the call bell to get out of bed prior to the dinner trays coming to the floor. Registered Nurse, Employee E6, told Resident R40 that staff could get the resident up after dinner trays were delivered and subsequently collected.
Continued review of the nursing note by Registered Nurse, Employee E6, revealed the resident [Resident R40] continued to ring the bell . [Resident R40] was asked what time she normally gets OOB (out of bed) and said 2 pm. I told her she can't blame the current shift for not getting her OOB earlier, and she didn't ask on 3-11 shift until right before dinner. [Resident R40] continues to ring her call bell as soon as it's turned off and her light has been answered multiple times to tell her they will get her out of bed right after dinner.
28 Pa. Code 211.10 (d) Resident Care Policies
28 Pa. Code 211.12 (c)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to clarify physician orders related to insulin, for one of two residents reviewed related to insulin (Resident R14).
Findings include:
Review of facility policy, Guidelines for Diabetes Mellitus dated reviewed June 2023, revealed that glucose monitoring guidelines include to check blood sugar level and frequency as ordered and for facility protocol in place for physician notification with specific parameters for notification.
Review of Resident R14's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 19, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose) and schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations). Continued review revealed that the resident received insulin (medication used to lower blood sugar levels) injections every day. Further review revealed that the resident had a BIMS (Brief Interview for Mental Status) of seven, indicating that the resident was severely cognitively impaired.
Review of Resident R14's care plan, dated initiated September 23, 2021, revealed that the resident was at risk for alteration in nutrition/hydration related to diabetes and to monitor for symptoms of hyper or hypoglycemia (high or low blood sugar levels).
Review of physician orders for Resident R14 revealed an order, dated October 28, 2021, for insulin lispro (type of insulin that is fast acting) inject eight units with meals. Continued review of the physician's order revealed that no additional instructions were provided.
Review of Medication Administration Records (MARs) for Resident R14 for February 2024 revealed the following:
On February 1, 2024, at 8:00 a.m. the resident's blood sugar was 98 and the insulin was not administered, documented as no insulin due;
On February 1, 2024, at 12:00 p.m. the resident's blood sugar was 99 and the insulin was not administered, documented as no insulin due;
On February 2, 2024, at 12:00 p.m. the resident's blood sugar was 78 and the insulin was not administered, documented as no insulin due;
On February 3, 2024, at 8:00 a.m. the resident's blood sugar was 128 and the insulin was not administered, documented as no insulin due;
On February 3, 2024, at 5:00 p.m. the resident's blood sugar was 61 and the insulin was administered;
On February 4, 2024, at 5:00 p.m. the resident's blood sugar was 77 and the insulin was administered;
On February 5, 2024, at 8:00 a.m. the resident's blood sugar was 77 and the insulin was administered;
On February 5, 2024, at 12:00 p.m. the resident's blood sugar was 71 and the insulin was administered;
On February 5, 2024, at 5:00 p.m. the resident's blood sugar was 98 and the insulin was not administered, documented as held-below parameters;
On February 8, 2024, at 5:00 p.m. the resident's blood sugar was 73 and the insulin was not administered, documented as hold - see nurses note;
On February 9, 2024, at 8:00 a.m. the resident's blood sugar was 88 and the insulin was not administered, documented as no insulin due;
On February 9, 2024, at 12:00 p.m. the resident's blood sugar was 90 and the insulin was not administered, documented as no insulin due;
On February 11, 2024, at 12:00 p.m. the resident's blood sugar was 97 and the insulin was not administered, documented as held-below parameters;
On February 12, 2024, at 8:00 a.m. the resident's blood sugar was 84 and the insulin was administered;
On February 12, 2024, at 12:00 p.m. the resident's blood sugar was 79 and the insulin was administered;
On February 13, 2024, at 8:00 a.m. the resident's blood sugar was 78 and the insulin was administered;
On February 13, 2024, at 12:00 p.m. the resident's blood sugar was 83 and the insulin was administered;
On February 13, 2024, at 5:00 p.m. the resident's blood sugar was 78 and the insulin was not administered, documented as no insulin due;
On February 14, 2024, at 12:00 p.m. the resident's blood sugar was 74 and the insulin was administered;
On February 14, 2024, at 5:00 p.m. the resident's blood sugar was 101 and the insulin was not administered, documented as held-below parameters;
On February 16, 2024, at 5:00 p.m. the resident's blood sugar was 105 and the insulin was not administered, documented as held-below parameters;
On February 18, 2024, at 5:00 p.m. the resident's blood sugar was 79 and the insulin was administered;
On February 19, 2024, at 8:00 a.m. the resident's blood sugar was 79 and the insulin was administered;
On February 19, 2024, at 12:00 p.m. the resident's blood sugar was 65 and the insulin was administered;
On February 22, 2024, at 8:00 a.m. the resident's blood sugar was 95 and the insulin was not administered, documented as hold - see nurses note;
On February 24, 2024, at 8:00 a.m. the resident's blood sugar was 100 and the insulin was not administered, documented as held-below parameters;
On February 24, 2024, at 5:00 p.m. the resident's blood sugar was 86 and the insulin was not administered, documented as held-below parameters;
On February 25, 2024, at 12:00 p.m. the resident's blood sugar was 98 and the insulin was not administered, documented as hold - see nurses note.
Review of progress notes, nurses notes and electronic MAR (eMAR) notes for February 2024 for Resident R14 revealed that there was no indication that the physician was notified of the resident's blood sugar levels or that the insulin was not administered on the above dates.
Further review of Resident R14's clinical record revealed that there were no prescribed parameters related to when to notify the physician or when to hold the prescribed insulin.
Interview on February 27, 2024, at 1:37 p.m. the Director of Nursing confirmed that the physician should have been notified when Resident R14's insulin was held/not administered. In addition, the Director of Nursing stated that the resident's insulin order needed to be clarified to include hold and physician notification parameters.
28 Pa Code 211.12(d)(3) Nursing services
28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview with resident and staff, review of clinical records and facility policy and procedures, it was revealed the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence for one of 34 resident records reviewed (Resident R122).
Findings include:
Review of the facility's policy titled, Bladder Incontinence Management Program, last revised October 2023 states the facility policy is to identify residents with urinary incontinence and provide an appropriate incontinence program based on incontinence status, 3-day elimination tracking and competition of a Comprehensive Bowel and Bladder assessment. The same policy instructs to consult therapy if applicable for evaluation of functional needs, develop and implement individualized interventions, discuss goals and interventions with resident and educate staff on toileting plan.
Review of Resident R122's clinical record revealed that the resident was was admitted to the facility on [DATE], with the diagnoses of Type Two Diabetes with ketoacidosis ( a life-threatening complication of diabetes) without coma, malnutrition, unspecified infection of the skin and subcutaneous tissue, and end stage renal (kidney) disease needing hemodialysis (acting as an artificial kidney).
During an interview on February 25, 2024, at 10:12 a.m. with Resident R122, the resident complained about wearing an adult brief and stated, I do not wear a diaper at home, in the hospital they gave me a commode or a bed pan, but not here, they give me a diaper. They (nursing staff) want me to go in my diaper when I have a BM (bowel movement) and don't want me to use the call bell until I soil myself.
Review of Resident R122's care plan dated January 22, 2024, revealed he was continent of bowel and bladder and indicated the resident was able to let the staff know when he needed to use the toilet. Interventions included meeting his toileting needs with dignity, nursing to check every two hours if the resident needed assistants.
Review of Resident R122's admission Bowel and Bladder assessment dated [DATE], revealed the prescreening questions asked, Based on a three- day bowel and bladder pattern observation, if the resident has had any episodes of incontinence, then a full assessment must be completed. The resident was documented as not continent of bowel or bladder (incontinent). Further review of the assessment revealed no documented evidence the full assessment was completed.
Interview conducated on February 27, 2024, at 10:30 a.m. with the Infection Control/Nurse Educator, Employee E11 revealed that Resident R122 was incontinent but when shown the care plan the nurse could not explain the discrepancy and confirmed the bowel and bladder assessment was not complete. The nurse also recommended contacting therapy for Resident R122's toileting status needs.
Interview with the Director of Therapy on February 27, 2024, at 1:00 p.m. stated on admission would recommend Resident R122 be a hoyer lifted (mechanical lift) due to his limited functional needs. The therapist also noted the resident had been making great progress in therapy since admission and was able to ambulate with therapy. When the surveyor asked what the requirements would be for using a bed pan it was explained therapy would not have to assess Resident R122 if he chose to use one.
Interview with Nursing aide (NA), Employee E12 on February 27, 2:00 p.m. revealed that she was not aware Resident R122 was continent of bowel and bladder as indicated on the care plan. When asked why he was given a brief not a bed pan, she explained, He was in a lot of pain when he first came here. I think he was in too much pain. The NA was informed of the resident stating in the hospital they offered him a bed pan or a commode, only here does he wear an adult brief. The aide agreed that she could see him using a bedpan now but was unaware he was continent.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with resident and staff and review of clinical records and facility policy, it was determined that the facility failed to ensure pain management was provided to a resident consistent with professional standards of practice, the comprehensive care plan and the resident's preferences for one of 34 resident records reviewed (Resident R230).
Findings include:
Review of facility policy titled Pain revised September 2022, stated the facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning.
Review of Resident R230 clinical record revealed he was admitted to the facility on [DATE], post discharge from the hospital where he was being treated after experiencing a seizure episode. Resident was noted as awake alert and oriented able to voice his needs and concerns.
Review of Resident R230's current care plan revealed that the resident was care plan for pain related to subdural hemorrhage initiated on February 23, 2024. Goals and interventions included to be pain free targeted date May 27, 2024 . Interventions included the resident communicate with the nursing staff when experiencing pain and to say what works to alleviate pain.
On February 25, 2024, at 1:00 pm surveyor observed resident in bed tearful and upset complaining of severe pain of 9/10 (10 being the most severe). The resident indicated a nurse gave him something for his pain a while ago but it never worked. Review of Resident R230 electronic administration record (EMAR) revealed an order for Tylenol, to be given for mild pain, was given at 8:45am for pain documented as 8 out of 10 administered by Licensed Practical Nurse (LPN) Employee E8 . The LPN was immediately interviewed at 1:09 p.m. and explained she had not re-assessed the resident since 8:45 a.m. when she initially administered the Tylenol. I was busy, and I am getting to it now. The surveyor questioned why the nurse administered Tylenol specified for mild pain when it was documented as severe. The nurse replied she did not know he was in pain.
Interview with the Director of Nursing on February 25, 2025 at 2:00 p.m. stated the nurse should have informed the doctor about his level of pain to provide him comfort and to ease the pain.
28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, it was determined that the facility failed accommodate the residents' needs by failing to provide proper bedding for sleeping for one of 34 residents reviewed (Resident R83).
Findings include:
Review of the clinical record revealed that Resident R83 revealed that the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease with respiratory infection (a lung infection), high blood pressure, and muscle weakness.
It was observed on February 25, 2024, at 10:00 a.m. Resident R83 appeared cold as he laid in bed using his coat as a blanket. The resident explained last night his blanket got wet and the aides told him there were none left. The resident said he used his coat as a blanket all night through the morning and was cold.
At the time of the observation and interview with Resident R83 nurse aide Employee E15 confirmed that the resident was without a blanket.
28 Pa. Code: 201.29(j) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 35 residents reviewed (Resident R128).
Findings include:
Review of Resident R128's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Colostomy Status (an operation that creates an opening for the large intestine, through the abdomen, to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter), and Dysphagia (difficulty swallowing) .
Review of physician order dated March 31, 2023, for Residnet R128, indicated an order stating, Resident has a colostomy on the Right Upper Quadrant.
On February 27, 2024, at 12:23 p.m. Resident R128 was observed having his colostomy bag attached to his colostomy site.
Review of the care plan for Resident R128, on February 27, 2024, at 2:12 p.m., revealed that there were no focus, interventions, and outcomes (goals) care- planned for Colostomy care.
On February 27, 2024, at 2:12 p.m., interview with Employee E9, a Licensed Nurse, confirmed the above findings.
28 Pa Code 211.10 (c)(d) Resident care policies
28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, interview with staff and residents and review of facility policy, it was determined that the facility failed to shower residents on a regular basis for seven out of seven residents reviewed (Residents R1, R2, R3, R4, R5, R6 and R7)
Findings include:
Review of facility policy on activities of daily living (ADL) documentation revealed that under policy Statement, all activities of daily living services provided to residents will be documented and will become part of the residents permanent record. Under section procedure. #1. The Certified Nursing Assistant and other licensed nursing personnel will assist residents in achieving maximum function and care by providing assistance with ADL's as needed. #2. ADL is a task related to personal care. ADL's include bed mobility, transfers, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene, and bathing. #4. All ADL assistance provided will be documented by the employee providing the care into the resident's Medical Record.
Review of Resident R1's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated November 1, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R1 scored 14 suggesting that Resident R1 was cognitively intact.
Review of Resident R1's shower record revealed that Resident R1 was not showered as scheduled on December 14, 2023 and December 30, 2023.
Interview Resident R1 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the facility did not have hot water for more than two weeks back in December and that he did not shower because the water was cold. Further Resident R1 also revealed that he washed himself using a washcloth but would have preferred a full shower. Further interview with Resident R1 revealed that he was not given the option to use the shower in Unit A and Unit C.
Review of Resident R2's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated November 15, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R2 scored 13 suggesting that Resident R2 was cognitively intact.
Review of Resident R2's shower record revealed that Resident R2 was not showered as scheduled on December 23, 2023.
Interview with Resident R2 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the facility did not have hot water for more than two weeks back in December and that he did not get showers because the water was cold. Further Resident R2 also revealed that he washed himself using a washcloth. Resident R2 also revealed that the water he used to wash himself with was cold and reminded him of the military. Resident R2 further revealed that he would have preferred a hot shower. Further interview with Resident R2 revealed that he was not given the option to use the shower in Unit A and Unit C.
Review of Resident R3's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated November 17, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R3 scored 15 suggesting that Resident R3 was cognitively intact.
Review of Resident R3's shower record revealed that Resident R3 was not showered as scheduled on December 3, 2023(refused), December 9, 2023, December 15, 2023, December 19, 2023(refused), December 26, 2023.
Interview with Resident R3 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the facility did not have hot water for more than two weeks back in December. Further Resident R3 also revealed that he usually washes himself in the toilet in his room using a washcloth. Further Resident R3 also revealed that he didn't want to shower with cold water. Further interview with Resident R3 revealed that he was not given the option to use the shower in Unit A and Unit C.
Review of Resident R4's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated November 4, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R4 scored 14 suggesting that Resident R4 was cognitively intact.
Review of Resident R4's shower record revealed that Resident R4 was not showered as scheduled on December 7, 2023(refused), December 11, 2023, December 14, 2023, December 18, 2023(refused), and December 25, 2023.
Interview Resident R4 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the water in the shower in December was cold so he couldn't take a shower for more than two weeks. Further Resident R4 also revealed that he had to use a washcloth to wash himself because he did not want to take a cold shower. Further interview with Resident R4 revealed that he was not given the option to use the shower in Unit A and Unit C.
Review of Resident R5's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated November 5, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R5 scored 15 suggesting that Resident R5 was cognitively intact.
Review of Resident R5's shower record revealed that Resident R5 was schedule to be showered on Mondays and Thursdays. Further review of resident R5's shower record revealed December 5, 2023 day and evening 16, 2023 evening shift was coded NA (not applicable), December 24, 2023 was coded refused and December 29, 2023 was coded NA. Further review of resident R5's shower schedule revealed that there was no other documented evidence that shower was offered or performed during the month of December 2023.
Interview Resident R5 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the there was no hot water last December and the water in the shower was cold. Further Resident R5 revealed that she wasn't showered for three weeks because of the lack of hot water. Further, resident R5 also revealed that she can do a lot of things for herself but that she needs assistance in the shower because she uses a wheelchair. Further, Resident R5 also revealed that she uses soap and water in the shower to clean herself but for three weeks she had to use a basin and a washcloth. Further interview with Resident R5 revealed that she heard that Unit A and Unit C had hot water but that she was not given the option to shower in Unit A and Unit C.
Review of Resident R6's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated January 8, 2024, section C0500 BIMS score (brief interview of mental status) revealed that Resident R6 scored 14 suggesting that Resident R6 was cognitively intact.
Review of Resident R6's shower record revealed that Resident R6 was not showered as scheduled on December 1, 2023(refused), December 5, 2023 (refused), December 8, 2023, December 18, 2023, and December 22, 2023 (no entry) and December 29, 2023.
Interview Resident R6 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that they didn't have hot water in the shower last in December and didn't get showered for three weeks because the water was cold. Further interview with Resident R6 revealed that he was not given the option to use the shower in Unit A and Unit C.
Review of Resident R7's MDS (Minimum Data Set- a federally required assessment completed at specific interval) dated December 22, 2023, section C0500 BIMS score (brief interview of mental status) revealed that Resident R'7 scored 14 suggesting that Resident R7 was cognitively intact.
Review of Resident R7's shower record revealed that Resident R7 was not showered as scheduled on December 1, 2023, December 8, 2023, December 16, 2023 (refused), December 20, 2023, and December 30, 2023.
Interview Resident 7 conducted during the tour of the facility on January 25, 2024, from 9:06 am to 10:56 am revealed that the B wing didn't have hot water in the shower last in December and that he also didn't get showered for three weeks because the water was cold. Further interview with Resident R7 revealed that he was not given the option to use the shower in Unit A and Unit C.
Interview with Employee E4 conducted on January 25, 2024, at 9:40 am revealed that during the time when the B wing had issues with hot water, the B wing had lukewarm water, however during certain times of the day, the water temperature would go down but never very cold. Further Employee E4 also revealed that she also used the showers in the A and C wings if the resident agrees.
Interview with Director of Nursing Employee E2 conducted on January 25, 2023, at 11:18 am revealed that residents were also given an option to shower in the A and C wing since there was no issue with water temperature in Units A and C.
28 Pa. Code 201.29(j) Residents right
28 Pa. Code 211.11(d)(1)(5) Nursing services

Based on observation, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for four of seven residents interviewed (Residents R7, R8, R9 and R11).
Findings include:
Observation of the menu posted on C Wing and E Wing on Monday, November 20, 2023, revealed that the menu included Monday lunch as Chicken Cacciatore with tomatoes, peppers and mushrooms, Bowtie Pasta, French [NAME] Beans and Chilled pears.
Observation of a test tray revealed a meal ticket which listed Chicken Cacciatore with tomatoes, peppers and mushrooms, Bowtie Pasta, French [NAME] Beans, Chilled pears, Cranberry Juice and milk. Further observation of the actual contents of the test tray revealed cut green beans which were dark and very soft and tasted mushy and overcooked (and were not French cut) and a cup of tropical mixed fruit which included papaya, mango and bananas (and no pears.)
Observation of Resident R7's lunch tray on November 20, 2023, at 12:15 p.m. revealed that she had also received the tropical fruit mix and not pears, and whole cut green bean, not French cut. Interview with Resident R7, an alert and oriented resident, revealed that missing food items and food items that are different from what is listed is an everyday occurrence, and she produced a stack of meal tickets which had the following problems:
November 17, 2023, lunch ticket says Capri Vegetables, served carrots;
November 20, 2023, breakfast ticket says French Toast served pancakes;
November 13, 2023, dinner ticket says green beans served cold, hard peas;
November 13, 2023, dinner ticket says diet chocolate pudding served butterscotch pudding with marshmallows;
November 13, 2023, dinner ticket says green beans served cold, hard peas;
November 13, 2023, dinner ticket says ketchup & mustard, no mustard on the tray;
November 19, 2023, breakfast ticket says hashbrowns, but there were none on her plate;
November 18, 2023, dinner ticket says coleslaw served whole kernel corn;
November 18, 2023, dinner ticket says diet lemon pudding served ice cream
November 18, 2023, dinner was served in a plastic clamshell with plastic utensils;
November 14, 2023, breakfast ticket says yogurt and pepper, neither were on the tray;
November 17, 2023, dinner ticket says diet ice cream served lemon water ice;
November 18, 2023, lunch ticket says watermelon served canned pears.
Interview with Resident R8, an alert and oriented resident, on November 20, 2023, at 12:25 p.m. revealed that she is often missing menu items that are listed on her menu but not on the tray.
Interview with Resident R9, an alert and oriented resident, on November 20, 2023, at 12:40 p.m. revealed that what is listed on her meal ticket is not always what is served, like today it said pears and I got this mixed fruit.
Interview with Resident R11, an alert and oriented resident, on November 20, 2023, at 12:45 p.m. revealed that sometimes she does not get what is listed on the ticket, and that they are usually short on condiments like she never gets mustard which is listed on her ticket when hot dogs are on, and she loves mustard on her hot dogs, but she never gets it.
Interview with Employee E6, Food Service Director, on November 20, 2023, at 1:05 p.m. confirmed that French green beans and pears were not served on the menu for lunch that day.
28 Pa. Code 211.6(a) Dietary services
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and a staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified timely about a change in condition requiring antibiotic therapy for one of four records reviewed (Residents R1).
Findings include:
A review of Resident R1's clinical records revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis to include acute respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide).
A review of Resident R1's nursing note dated July 21, 2023, by Licensed nurse, Employee E10, revealed that Resident R1 had medium amount of lose stools during morning care with a slight smell and brown in color. Stool sample collected to test for C-Diff (Clostridioides difficile, is a bacterium that causes an infection of the large intestine) and stool softeners discontinued per doctor's orders. Further review revealed another progress note written on July 21, 2023, by Licensed nurse, Employee E9, stating Resident R1's labs were reviewed with the physician that the stool specimen was positive for toxigenic C-Diff and a new order for Vanmycin (an antibiotic medication used to treat a number of bacterial infections including C-Diff) 250 mg tab by mouth four times per day for 14 days was written. Still further review revealed a July 22, 2023, progress note by Employee E11 which read day 1 of 14 for antibiotic vancomycin by mouth for C-Diffx, and that Resident R1's first dose was this shift at 6:00 a.m. Continued review of Resident R1's progress notes did not reveal any documented evidence that the facility contacted Resident R1's responsible party about the lab results or the physician's order to start antibiotic treatment for the C-Diff infection.
A review of Resident R1's vital statistics revealed a blood pressure (BP) log with low BP warnings set at 60 mmHg (millimeter of mercury is a unit used to measure pressure) for diastolic pressure (diastolic blood pressure is the measurement during this pause (diastole) before the next heartbeat, bottom number in BP), and 90 mmHg for systolic pressure (is the measure of this pressure within the arteries while the heart beats. This phase, known as systole, is the point at which blood pressure is the highest, top number in BP). Further review of Resident R1's BP log revealed that on August 8, 2023, BP was 105/59, on August 9, 2023, BP was 90/52, on August 14, 2023, at 9:02 p.m. BP was 103/59, on August 15, 2023, at 4:29 p.m. BP was 94/42 and on August 15, 2023, at 10:39 p.m. BP was 76/36.
A review of Resident R1's progress notes reveals no notification to the responsible party for any of the low blood pressure measurements which were below the warning parameters.
An interview with the Director of Nursing on November 20, 2023, at 1:20 p.m. confirmed that Resident R1's responsible party should have been notified about the antibiotic for the C-Diff infection and for the low blood pressures and that this should have been documented in the progress notes.
28 Pa. Code 201.29(c.3)(1) Resident rights
28 Pa. Code 211.12(d)(1) Nursing services

Based on the review of facility policy, interviews with staff, and review of facility documentation, it was determined that the facility failed to release requested clinical records to resident representative in a timely manner for one of Five residents reviewed. (Resident R1)
Findings Include:
Review of facility policy, Medical Record Release dated May 1, 2023, revealed that It is imperative that all medical record request for release of information be addressed in a timely manner as they are time sensitive. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his legal representative(sponsor), consistent with state laws and regulations. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hours (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services at the prevailing rate.
Interview with medical record director, Employee E3, on August 2, 2023, at 12:30 p.m. stated facility should complete all medical record request within 30 days of the request. Immediately after the request the facility should notify the resident/representative or entity requesting the record a fee for copying the record.
Review of medical record request for Resident R1 revealed that a request for medical record was submitted by the resident POA on April 13, 2023. Further review of the documentation revealed that no POA documentation was available with the request and the request was not completed. It was also revealed that no information was provided about the cost of the service at the time of request.
Review of clinical record revealed that in June 22, 2023 a request was submitted to sent an invoice about the cost of the medical record along with the POA information.
Continued review of the medical record documentation revealed that no invoice or the amount for medical record was communicated to the POA until July 27, 2023.
Interview with medical record director, Employee E3, on August 2, 2023, at 12:30 p.m. confirmed that the facility did not notify the cost of the medical record release in a timely manner or released the medical record in a timely manner.
28 Pa. Code 211.5(f) Clinical records.