Based on interviews with residents and staff, observations, and review of facility policy, it was determined the facility did not ensure the residents' right to file a grievance anonymously was available for the residents for nine of nine residents interviewed (Resident R15, 16, 26, 28, 29, 39, 42, 43, and 159). Findings include: Review of the facility's policy titled Resident Concerns/Grievances not dated states, The resident or family has the right to file a grievance anonymously by using the locked boxes on the households which are routinely checked by the DON (Director of Nursing). During resident council on May 22, 2025, at 10:00 a.m. with nine alert and oriented residents (Resident R15, 16, 26, 28, 29, 39, 42, 43, and 159) all agreed that they were not aware it was their right to be able to file a grievance anonymously. During an interview and observation with Community Life Leader, Employee E6, on May 22, 2025, at 11:30 a.m., a sign posted in one of the three skilled nursing units titled Notice of Grievance Procedures indicated the residents had the right to file a grievance and may file a grievance anonymously. The surveyor did not observe a designated area where the anonymous grievance would be submitted. Employee, E6 pointed to the box labeled suggestion box. The Directof of Nursing confirmed On May 23, 2025, at approximately 11:30 a.m., there will be a box labeled for anonymous grievances. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)Resident rights

**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 did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one of 16 residents reviewed. (Resident R28) Findings Include: Review of the facility policy titled Abused or Neglected Residents revied 2023, states the resident has the right to freedom from neglect and protects residents from real or perceived abuse or neglect from any source. The policy defines neglect as deprivation by an individual, including caretaker, a facility, its employees, or service providers to provide good and services that is necessary to attain or maintain physical mental emotional psychosocial well-being. The same policy states that the investigation will include the witness(es) interview and signed statement will be obtained. Any suspected or alleged abuse will be reported to the Department of Health. Resident R28 was admitted to the facility on [DATE], with heart failure, and atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of nursing note dated February 5, 2025, stated the resident alerted the staff that she spilled coffee on herself. Upon the nurse's assessment the resident was noted with scattered intact blisters to the right abdominal area, under right breast and upper right thigh. Interview with Resident R28 on May 23, 2025, at approximately 1:00 p.m. indicated she was given her cup of coffee sitting up in bed and fell asleep with the cup in her hand. The resident stated, At first, I didn't realize it because it didn't hurt. I didn't tell nursing until later. Interview with the Director of Nursing on May 22, 2025, at approximately 9:30 a.m. stated the incident was not reported to State Survey Agency. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for one of 16 residents reviewed. (Resident R28) Findings include: Review of the facility policy titled Abused or Neglected Residents revised 2023, states the resident has the right to freedom from neglect and protects residents from real or perceived abuse or neglect from any source. The policy defines neglect as deprivation by an individual, including caretaker, a facility, its employees, or service providers to provide good and services that is necessary to attain or maintain physical mental emotional psychosocial well-being. The same policy states that the investigation will include the witness(es) interview and signed statement will be obtained. Any suspected or alleged abuse will be reported to the Department of Health. Review of Resident R28 was admitted to the facility on [DATE], with heart failure, atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of nursing note dated February 5, 2025, stated the resident alerted the staff that she spilled coffee on herself. Upon the nurse's assessment the resident was noted with scattered intact blisters to the right abdominal area, under right breast and upper right thigh. Review of facility investigation and interview with dining coordinator, Employee E7 May 22, 2025, at 12:00 p.m. who placed the coffee on the resident's breakfast tray and the aide Employee E8 on May 23, 2025, at 11:30 p.m., who served the coffee to Resident R28, confirmed the facility failed to obtain the written witness statement to rule out any possibility of neglect. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee

Based on review of facility provided documentation, review of clinical record, and interview with staff, it was determined that facility did not provide Covid-19 immunizations according to professional standards of practice for 35 of 73 residents reviewed (Residents R7, R26, R35, R27, R48, R43, R29, R18, R177, R15, R178, R20, R14, R38, R166, R167, R168, R169, R170, R171, R172, R173, R174, R8, R175, R176, R179, R180, R39, R37, R9, R46, R40, R22, R181) Findings include: Review of facility provided policy 'Immunization Policy,' unknown date, indicates that All residents, staff and volunteers will be offered covid-19 vaccine per the Centers for Disease Control and Prevention (CDC) recommendations. According to CDC Epidemiology and Prevention of Vaccine-Preventable Diseases, revised on April 22, 2024, indicates that The key to preventing serious adverse reactions after vaccination is effective screening. Every patient should be screened for contraindications and precautions before administering any vaccine dose. Further review of facility's policy 'Immunization Policy,' unknown date, indicates that these vaccines will be administered by any appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. According to §483.80(d)(3) COVID-19 immunizations, The LTC facility must develop and implement policies and procedures to ensure all the following: When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized. (Screening individuals prior to offering the vaccination for prior immunization, medical precautions and contraindications is necessary for determining whether they are appropriate candidates for vaccination at any given time.) Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R7 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R26 was administered covid-19 immunization on October 14, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R35 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R27 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R48 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R43 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R29 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R18 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R177 was administered covid-19 immunization on December 17, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R15 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R178 was administered covid-19 immunization on October 26, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R20 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R7 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R14 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R38 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R166 was administered covid-19 immunization on November 8, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R167 was administered covid-19 immunization on February 22, 2025. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R168 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R169 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R170 was administered covid-19 immunization on October 15, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R171 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R172 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R173 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R174 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R8 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R175 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R176 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R179 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R180 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R39 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R37 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R9 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R46 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R40 was administered covid-19 immunization on April 24, 2025. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R22 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R181 was administered covid-19 immunization on October 14, 2024. Review of residents' clinical records revealed no evidence of completed screening prior to covid-19 immunizations. Interview with facility's infection preventionist, Employee E4, on May 21, 2025 at 2:00 p.m. confirmed facility did not complete screenings on the residents listed above as required. 28 Pa Code 201.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews review of clinical records and facility policy, it was determined the facility failed to have a scheduled maintenance for residents' bed rails to ensure safety for one of 16 resident records reviewed (Resident R28). Findings include: Review of the facility's undated policy titled Bed Rails states the facility will ensure individual bed rail assessments and evaluations are performed on a regular basis. Resident was admitted to the facility on [DATE], with heart failure, atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of Resident R28's nursing note revealed an incident on March 11, 2025, the resident was found on the floor with a hematoma (bruise) to the left side of the head. The nurse noted that the right-side bed rail was broken, right side rail was in up position but would not lock in place. Interview with the Director of Maintenance on May 22, 2025, at 9:00 a.m. stated the bed rails were checked only at the time that a room was prepare for a new admission. Since the incident the Director of Maintence stated we now check the bedrails monthly since the incident. 28 PA Code 201.18(b)(1) Management

Based on review of facility provided documentation, review of clinical record, and interview with staff, it was determined that facility did not ensure to provide pneumococcal immunization according to professional standards of practice for one of 73 residents reviewed (Resident R165) Findings include: Review of facility provided policy 'Immunization Policy,' unknown date, indicates that All residents will be offered the Pneumococcal vaccine per Centers for Disease Control and Prevention (CDC) recommendations (age/timing of previous vaccine). According to CDC Epidemiology and Prevention of Vaccine-Preventable Diseases, revised on April 22, 2024, indicates that The key to preventing serious adverse reactions after vaccination is effective screening. Every patient should be screened for contraindications and precautions before administering any vaccine dose. Further review of facility's policy 'Immunization Policy,' unknown date, indicates that these vaccines will be administered by any appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. Review of facility provided documentation on May 21, 2025, 12:00 p.m., revealed Resident R165, received pneumococcal immunization on August 27, 2024. Review of R165's clinical record revealed no evidence of completed screening prior to immunization. Interview with facility's infection preventionist, Employee E4, on May 21, 2025 at 2:00 pm, confirmed that facility does not complete screening for pneumococcal immunizations prior to administration. 28 Pa Code 210.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12 (c)(d) (10) nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, and review of clinical records it was determined that the facility failed to develop a person-center, comprehensive care plan related to impaired skin integrity for one of 15 residents reviewed (Resident R26). Findings Include: Review of facility policy Care Planning, undated, revealed a care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs. The resident's comprehensive care plan is developed within 7 days of submission of the complete MDS (Minimum Data Set - federally mandated resident assessment and care screening) assessment. Review of Resident R26's quarterly MDS dated [DATE], revealed the resident had short and long-term memory problems and was at risk of developing pressure ulcers. Review of facility skilled wound report dated August 15, 2024, by Licensed Nurse, Employee E5, revealed Resident R26 had a deep tissue injury (DTI - localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) of the right fifth toe with an onset date of July 11, 2024. Review of Resident R26's care plan revealed no documented evidence the facility developed or implemented a person-centered, comprehensive care plan with measurable objectives and timetables to address the resident's impaired skin integrity. 211.10 (d) Resident care policies.

Based on observations, review of facility policy, and staff interviews it was determined that the facility failed to implement procedures to ensure food was served at safe, appetizing temperatures for one of six residents observed in the dining room (Resident R31). Findings Include: Review of facility policy Food Temperatures, undated, revealed microwave re-heating is appropriate and acceptable when a resident requests to have their food reheated. Upon removal of the food from the microwave, the food will be stirred or rotated and then allowed to stand covered for two minutes before served to assure that the temperature will be under 180 degrees Fahrenheit. Review of Resident R31's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) revealed the resident had moderate cognitive impairment and had diagnoses of muscle weakness and dementia (group of symptoms affective memory, thinking abilities, and social abilities). Observations on August 21, 2024, at 12:35 p.m. in the Park dining room revealed dietary aide, E4, heated up a plate of food (hot dog and beans) for Resident R31. Further observations revealed dietary employee, E4, removed the plate from the microwave and handed it directly to the nurse aide to serve to Resident R31 without checking the temperature or letting it sit to come down to the proper temperatures. Subsequent interview on August 21, 2024, at 12:35 p.m. with dietary aide, Employee E4, confirmed the temperature of the food was not checked to ensure it was being served at safe temperatures. 211.12 (d)(5) Nursing services.

Based on observations, review of clinical record, and staff interview it was determined that the facility failed to provide beverages consistent with resident needs for one of six residents reviewed with altered fluid consistency (Resident R17). Findings Include: Review of Resident R17's clinical record revealed a physician order dated August 18, 2024, that revealed Resident R17 was ordered nectar consistency liquids (beverages that are thicker than water and fall slowly from a spoon). Observations on August 21, 2024, at 10:00 a.m. revealed Resident R17's breakfast tray was sitting on the overbed table in the resident's room. Observations revealed the meal ticket indicated Resident R17 was to be provided nectar thick liquids. Further observations revealed Resident R17 was provided with orange juice that was of thin, regular, consistency. Interview on August 21, 2024, at 10:05 a.m. with Nurse Aide, Employee E3, confirmed Resident R17 was provided with the wrong beverage. 211.10 (c) Resident care policies. 211.12 (d)(5) Nursing services.

Based on review of facility policy/Infection Control Program Overview, interview staff, review of facility record, it was determined that the facility failed to designate one or more individual as the infection preventionist who work at least part time at the facility. Findings include: Review facility Infection Control Program Overview, under section Goals: The goals of the infection control program are to #a Decrease the risk of infection to residents and personnel #b Monitor for occurrence of infection and implement appropriate control measures. #c Identify and correct problems relating to infection control practices #d ensure compliance with the state and federal regulations relating to infection control. Under section Division of Responsibilities for Infection Control Activities: the administrator is ultimately responsible for the infection control program. #A. Infection control practitioner or designee Responsibility is delegated to a staff member acting as the infection control practitioner or to a trained infection control practitioner to carry out the daily functions of the infection control program. Those functions are described in the Infection Control practitioner job description. The infection control practitioner or designee has knowledge and interest in infection control. Interview with Director of Nursing Employee E2 conducted on August 21, 2024, at 12:45pm confirmed that Employee E2 was the full time Director of Nursing at the facility. Further interview with Employee E2 also revealed that while being the full time Director of Nursing, Employee E2 was also the infection preventionist for the facility and that she was the only employee in the facility with an infection control certification. Follow-up interview with Employee E2 conducted on August 23, 2024, at 10:46 am revealed that Employee E2 also revealed that she does not clock in because she is a salary employee. Further Employee E2 also revealed that there was no documented evidence that she also worked part time as an infection preventionist. 28 Pa. Code 210.18(e)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review facility policy, and interview with staff, it was determined that the facility failed to ensure the residents were provided with education regarding the benefits and potential side effects of influenza immunization for two of two residents reviewed (Resident R29 and Resident R14). Findings: Review facility policy on Influenza and Pneumococcal Vaccination revealed that under section Policy, it is the policy of [NAME] that each resident is to be protected against the influenza virus. Influenza vaccine will be offered for each resident annually. Under section Purpose to control a potential outbreak and prevent residents, visitors, and employees from being infected by the influenza virus. Under section procedure #1. Up and admission, readmission and annually the residence medical record will be reviewed for a history of influenza pneumococcal vaccination. #3 Each year the influenza vaccination is offered in a high dose for residents over [AGE] years of age and if indicated, the resident will be offered pneumococcal vaccination. If the resident/resident representative declines education about risk and complications of not receiving the influenza or pneumococcal vaccine will be discussed. #5 An order to administer the influenza vaccination each year will be obtained. #6 The resident will receive the influenza vaccination as ordered. Review of Resident R29's clinical record revealed no documented evidence that before offering the influenza immunization, Resident R29 received education regarding the benefits and potential side effects of the immunization. Review of Resident R14's clinical record revealed no documented evidence that before offering the influenza immunization, Resident R14 received education regarding the benefits and potential side effects of the immunization. Interview with Director of Nursing Employee E2 conducted on August 23, 2024, at 10:46 AM revealed that residents and families are provided with consent forms for vaccinations upon admission on ly and only asks the residents verbally if they want the vaccines at the beginning of each flu season. Further, Employee E2 confirmed that there was no documented evidence that the residents or the resident representatives received education regarding the benefits and potential side effects of influenza immunization. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to provide appropriate Activity of Daily Living (ADL) for two of 6 residents reviewed who were unable to carryout ADL care independently. (Resident R1 & R3) Findings include: Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R1 dated April 2, 2024, revealed that the resident was dependent on the staff for showers, transfers, and toileting. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 8 which indicated that the resident's cognitive status for daily decision making was moderately impaired. Clinical record indicated that Resident R1 was scheduled for showers on Wednesday and Saturday from 7-3 shift. On June 13, 2024, at 2:35 p.m. a review of Shower Task Performance Documentation with the Director of Nursing revealed and confirmed that Resident R1 was not given showers on Wednesdays May 8, 15, 22, 2024 and June 5, 2024, as per her schedule. Review of Resident R3's clinical record review indicated that Resident R6 was admitted to the facility on [DATE]. Clinical record indicated that Resident R3 was scheduled for showers/bed baths on Tuesday and Fridays. On June 13, 2024, at 10:29 a.m. an interview and observation held with Resident R3 who was in lying in bed mid-size facial hair, long hair, and long nails. The long hair looked greasy and dead white flakes on the top of his/her hair. Resident when questioned if he/she desires to cut his hair, facial hair, and nails. Resident R3 responded yes but I'm unable to do it myself. Resident R3 prefers bed baths over shower as he/she has colostomy bag. This observation was confirmed by License Nurse, Employee E5. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed related to toileting program, tubi-grips, gel cushion to wheelchair, for one resident of six residents reviewed. (Resident R1) Findings include: Review of facility policy, Medication Order undated, revealed, it is the policy of [NAME] Lutheran to establish uniform guidelines in the receiving and recording of medication orders. To ensure safe and effective use of medications and that medication information on residents is captured, used and communicated. Review of active physician order for Resident R1 revealed an order dated December 11, 2023 toileting schedule: Take resident to the bathroom/offer toileting resident at around 8:00 a.m., 11:00 a.m., 2:00 p.m., 5:00 pm, 8:00 p.m. check and change as need while asleep. Order dated May 1, 2023 tubi-grips to bilateral lover extremities place on in am and remove at bedtime. On November 3, 2022, to gel cushion to wheelchair check placement and integrity every shift. A review of the Task Documentation for Toilet Use from May 1, 2024 -June 12, 2024, the following dates did not document 11:00 am toileting attempt: May 1, 2,3, 4,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25,26,27,28,29,30,31, 2024 June 2, 3,4,5,6,7, 8, 9, 10, 11, 12, 2024 On June 13, 2024, at 10:39 a.m. to 11:15 a.m. interview and observations were completed in the living room of Resident R1 participating in activities but was not taken to the complete a toilet program per the physician order at 11am. Further observations were completed during the same day from 12:22 p.m. to 2:05 p.m. with Resident R1 who as having lunch and then transitioned to the living room for activities. There was no implementation of toileting program at 2pm. On June 13, 2024, at 12:37 p.m. observations made with Rehabilitation Director, Employee E13 that Resident R1 was sitting in her wheelchair eating lunch and had wheelchair foot rest heel loops/strips which would prevent the resident's heel to slide backwards was broken off on the right side. Resident R6 was sitting at the same dining table with Resident R1 and had a foot rest loop broken off as well on the left side. Employee E13 replaced it with new [NAME] and reported that there was no need for the [NAME] loops to be attached. On June 13, 2024, at 1:05 p.m. observation was taken place that Resident R1 was sitting in the dining room with no tubi-grips per the physician order. License Nurse, Employee E5 confirmed the observation and reported I must have forgot. Employee E5 went into Resident R1's room to locate tubi-grips and there was nonavailable. Employee E5 stated I will have to order it. 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, resident and staff interviews, it was determined that the facility failed to implement individualized approaches to restore normal bladder function and prevent continued decline of bladder continency for one of one resident reviewed for bowel and bladder management (Resident R38). Findings include: Interview with Resident R38 on October 11, 2023, at 11:54 a.m. stated she was continent 6 weeks ago, now she was incontinent after her recent hospitalization. Resident stated she was not using her bathroom or staff did not make any toileting plan. A review of Resident 38's admission assessment dated [DATE], revealed an assessment of resident's genitourinary system review which indicated that the resident was incontinent of urine, and she had a new onset of incontinence. Further review of the assessment revealed that the resident also had bowel incontinence. A review of Resident 38's bladder elimination record from September 19, 2023, to October 13, 2023, revealed the resident had 58 documented occurrences of incontinence. It was also revealed that continent of bladder was documented 6 times. Review of Resident R38's admission MDS (Minimum Data Set- assessment of resident care needs) dated September 26, 2023, revealed that the resident was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Further review of the MDS revealed that there was no trial of a toileting program (e.g. Scheduled toileting, prompted voiding, or bladder training) been attempted on admission or reentry or since urinary incontinence was noted in the facility. Review of the resident's plan of care dated September 20, 2023, revealed that the resident was noted with new onset of urinary incontinence with interventions included, evaluate if resident was aware of the need to void, evaluate for urinary complaints, evaluate medication schedule and possible pharmacological causes of new urinary incontinence, and evaluate resident's ability for toileting self-care. Review of clinical record for Resident R38 revealed no documented evidence that the staff assessed and implemented interventions to restore urinary continence or to prevent further decline in urinary continence. Interview with the Director of Nursing on October 13, 2023, at 11:00 a.m. confirmed that the facility did not implement interventions to restore urinary continence or to prevent further decline in urinary continence for Resident R38. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to implement psychiatry recommendations in a timely manner for one of two residents reviewed for behavioral health services (Resident R26). Findings include: Review of nursing progress note for Resident R26 dated August 18, 2023, revealed that the resident refused repositioning and at times refused care despite of continuous education and encouragement. Review of nursing progress notes for Resident R26 dated September 1, 2023, September 4, 2023 and September 10, 2023 revealed that the resident refused shower and at times refused care. Further review of nursing progress note for Resident R26 dated September 10, 2023, revealed that the resident was combative during treatment, and he was rolling nurses aide's wrist. The resident repeatedly hit the nurse. Review of resident's care plan for Resident R26 dated June 6, 2023, revealed that the resident had behavioral problem with interventions included, administer medications as ordered. Monitor/document for side effects. Review of Psychiatry Note for Resident R26 revealed that the staff stated resident was irritable and at times uncooperative. It was also revealed that the psychiatrist recommended to increase resident's Bupropion (It can treat depression) to 100 milligrams (mg) in the morning and 50 mg in the evening for irritability and low motivation. Review of physician orders for Resident R26 revealed an active physician's order, dated August 15, 2023, for Bupropion 50 mg twice daily. Continued review of physician orders revealed that there were no orders to adjust the dosage of the Bupropion as per the psychiatrist's recommendations. Interview on October 13, 2023, at 11:00 a.m., with. Employee E2, Director of Nursing, confirmed that there was no documented evidence that the psychiatrist recommendation was addressed by the staff or attending physician. 28 Pa Code 211.2(a) Physician services 28 Pa Code 211.12(d)(3) Nursing services

Based on observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for one of two medication carts observed. (Second floor medication cart). Findings Include: Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening. Review of manufacturer's guidelines for Lantus Insulin(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Basaglar(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolog Insulin (insulin aspart) revealed that the medication must be discarded 28 days after opening. Unopened vials should be refrigerated unit use. Observation on October 11, 2023, at 9:20 a.m. of the second-floor medication cart with Registered Nurse, Employee E11, revealed open and undated vials of insulin pen, Basaglar, Humalog, Lantus and Novolog in room temperature. Further observation of the mediation cart revealed opened Refresh eye drops, Tobramycin eye drops, Latanoprost eye drops, and Timolol eye drops with no open date or expiration date. Interview with Licensed nurse, Employee E11, on October 11, 2023, at 9:20 a.m. stated staff label insulin pens and eye drops with open dates and expiration dates. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safely. Findings Include: Review of facility policy titled: PQA: Food Product Shelf Life Guidelines with the last revision date of January 28, 2022 it states, Safety of food after expiration dates: dates usually refer to best quality and are not safety dates. Products with a Sell by, or Best By or (Before) or Use-By: Adhere to that date for quality reasons. Further review of facility policy titled: PQA: Food Product Dating Reference with the last revision date of August 1, 2020 states, What is the safety of food after expiration dates? Products with a use by date, follow that date. An initial tour was conducted on October 10, 2023 at 10:03 a.m. of the first floor rehabilitation unit's satellite kitchen. The toured revealed a freezer with hot dogs unlabeled and storage in a way that it was exposed to air. Three hamburger patties in the freezer with visible freezer burned and storage in a way that it was exposed to the air. An initial tour of the kitchen was conducted on October 10, 2023 at 10:33a.m. with Employee E5, Director of Dining Services. A tour of the walk in dry store pantry revealed the following: two bags of pasta open in the pantry unlabeled and one bag of brown sugar opened in the pantry unlabeled. Observation of the walk in refrigerator revealed: two fresh fruit past date of Use by October 5, 2023 and four fresh fruit past date of Use by October 8, 2023. There were six bags of lettuce with a Use by date of October 7, 2023. Observation of the walk in freezer revealed: a meatloaf tray with a date of October 3, 2023 and spaghetti tray with freezer burn dated October 6, 2023. Both trays of food were not wrapped properly with saran plastic wrap, exposed them to the elements of the freezer causing them to be freezer burned. This conclusion was confirmed by Employee E5, Director of Dining. An initial tour was conducted on October 10, 2023 at 12:34 p.m. of the second floor unit's satellite kitchen. The tour revealed items in the dry store pantry unlabeled: a large container of peanut butter, and two large plastic containers of cereal. One large container of cereal half full with an open date labeled June 11, 2023. Interview at the time of observation with the chef, Employee E9, revealed items get sent up from the main kitchen to the satellite kitchens and should be labeled when they get up to the satellite kitchens. 28 Pa Code: 201.14(a) Responsibility of licensee 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management