Based on clinical record review, staff interview, and Centers for Medicare and Medicaid Services publication, it was determined that the facility failed to complete a Significant Change Minimum Data Set after a significant change was identified for one of two residents reviewed for hospice services (Resident 45). Findings include: Review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 (instructions on when and how to complete the Minimum Data Set), revealed it stated, An [Significant Change in Status Assessment; a.k.a. Significant Change Minimum Data Set] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The [Assessment Reference Date] must be within 14 days from the effective date of the hospice election . Review of Resident 45's clinical record revealed diagnoses that included Alzheimer's disease (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). Review of Resident 45's clinical record revealed that on July 22, 2024, Resident 45 entered into hospice services. Review of the Minimum Data Set (MDS) assessment history for Resident 45 revealed that a Significant Change MDS was not completed until September 13, 2024; 53 days after Resident 45 had entered into hospice services. During a staff interview on March 13, 2025, at approximately 11:10 AM, Nursing Home Administrator (NHA) confirmed that the Registered Nurse Assessment Coordinator identified that Resident 45 did not have a Significant Change MDS completed within 14 days, and subsequently completed the Significant Change MDS with an assessment reference date of September 13, 2024. During the interview, the NHA confirmed that it was the facility's expectation that Significant Change MDS assessment are completed within 14 days after the facility identifies significant change in resident condition. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Residents 7 and 20). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 7's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated November 1, 2024, revealed that in Section N, opioid medication (a class of drug used to reduce moderate to severe pain) was not checked as being received by the resident during the last seven days. Review of Resident 7's medication administration record (MAR), dated October 2024 and November 2024, revealed that Resident 7 received Tramadol (an opioid medication) every day. On March 13, 2025, at 11:47 AM, the Nursing Home Administrator (NHA) confirmed that Resident 7 received the Tramadol and that the opioid medication should have been coded on the MDS. Review of Resident 20's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus. Further review of Resident 20's clinical record revealed that he was admitted to the hospital on [DATE], and readmitted to the facility on [DATE]. Review of Resident 20's hospital Discharge summary, dated [DATE], revealed that he was diagnosed with a UTI (urinary tract infection) during his hospital admission. Review of Resident 20's physician note, dated January 3, 2025, revealed that Resident 20 was diagnosed with a UTI during his hospitalization. Review of Resident 20's MAR, dated January 2025, revealed that Resident 20 received Levaquin (antibiotic) on January 4-7, for treatment of his UTI. Review of Resident 20's significant change MDS, dated [DATE], revealed in section I, it was not coded that Resident 20 had a UTI in the past 30 days. Further review of the MDS revealed in Section N, it was not coded that Resident 20 received an antibiotic in the past seven days. On March 13, 2025, at 10:32 AM, the NHA stated that the UTI was missed being coded on the MDS and one day of antibiotic should have been coded during the seven day lookback period. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 29 and 46). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety. Further review of Resident 29's clinical record revealed that Resident 29 was transferred and admitted to the hospital on [DATE], after a fall, resulting in a left femur fracture and right calcaneus (heel bone) fracture. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), revealed Resident 29 had a significant change MDS assessment completed on March 29, 2023, which was the first assessment completed after Resident 29's re-entry to the facility. Review of Resident 29's significant change MDS dated [DATE], revealed that in Section A0310E, which asks Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? was coded as 0/No. Review of section J1700, Fall History on Admission/Entry or Reentry, revealed Complete only if A0310A = 01 or A0310E = 1. Since section A0310E was coded as a 0, Section J1700 was not coded and Resident 29's fall with fracture was not captured on the MDS. In an email correspondence from the Nursing Home Administrator (NHA) on May 10, 2023, at 6:00 PM, she stated that Section A was miscoded and, therefore, did not populate for J1700. She stated that a modification MDS has been completed. In a follow up interview with the NHA on May 11, 2023, at 11:11 AM, she confirmed that Resident 29's MDS was coded incorrectly in Section A, which caused Section J to not capture Resident 29's fall with fracture. Review of Resident 46's clinical record revealed diagnoses that included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident 46's physician's orders revealed an order dated November 11, 2022, to discharge Resident 46 from hospice services on November 16, 2022. Review of Resident 46's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 25, 2022, revealed that Section O0100k. Hospice Care was not checked, indicating that Resident 46 had not received hospice care in the previous 14 days while a Resident or while not a Resident. Also, O0100z. None of the above, was checked indicating that Resident 46 did not receive any of the above treatments (including hospice care) in the previous 14 days Interview with the NHA on May 10, 2023, at 6:14 PM, revealed that Resident 46 had received hospice services during the 14-day look-back prior to the November 25, 2022, MDS and should have been marked accordingly. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident 4). Findings Include: Review of facility policy, titled Dressings: Clean, with a review/revision date of November 2021, revealed Remove soiled dressings and discard in bag. Remove gloves. Wash hands. Put on clean gloves. Use either swabs or gauze pads to clean area. Review of Resident 4's clinical record revealed diagnoses that included heart failure, atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow), and left hip pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Review of Resident 4's current physician orders revealed an order dated April 28, 2023, to cleanse left hip pressure ulcer with normal saline solution (NSS), apply skin prep to around wound, apply calcium alginate with silver to wound bed, and cover with foam dressing. Observation of Resident 4's dressing change to the left hip pressure ulcer on May 10, 2023, at 10:45 AM, revealed Employee 1 performing hand hygiene and applying gloves. Employee 1 then removed Resident 4's old dressing and discarded it into the trash. Employee 1 then cleansed Resident 4's pressure ulcer with NSS. Employee 1 did not remove her gloves, perform hand hygiene, and apply a new pair of gloves after removing the old dressing and before cleansing the pressure ulcer with NSS. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 11, 2023, at 11:09 AM, the NHA stated that the facility policy should have been followed; and Employee 1 should have changed her gloves and performed hand hygiene after removing the old dressing and prior to cleansing the wound. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 18 residents reviewed (Residents 24, 46, and 55). Findings include: Review of Resident 24's clinical record revealed diagnoses that included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Stage 3 Pressure Ulcer (a full thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) of the sacral region (the portion of the spine between the lower back and tailbone). Review of Resident 24's care plan revealed problems for Impaired skin integrity which indicated a goal of: Resident's current stage 3 coccyx pressure ulcer will resolve without complications or infection and Resident will develop no further skin breakdown, with a goal date of November 24, 2022. Further review revealed a care plan for Risk for skin integrity impairment related to Braden Assessment (an assessment tool used to identify a person's risk level for skin breakdown) and risk factors of diabetes, limited mobility, incontinence, poor appetite with weight loss, declining health, and need for increased assistance with activities of daily livings, which indicated a goal of: Resident will be free of skin breakdown, with a goal date of November 24, 2022. Resident 24 also had a care plan for Psychotropic (medications that affect a person's mental state) drug use with potential drug related complications related to antidepressant and antianxiety medication use with diagnoses of major depressive disorder and anxiety disorder; recent weight loss; and reports feeling depressed and tired, which indicated a goal of: will remain free of drug related cognitive/behavioral impairment; gait disturbance; hypotension; movement disorder, with a goal date of December 7, 2022. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2023, at 2:40 PM, the concern of Resident 24's care plan goal dates was shared for further follow-up. Email communication received from NHA on May 10, 2023, at 6:18 PM, indicated that Resident 24's care plan goal dates were revised. During an interview with the NHA on May 11, 2023, at 9:45 AM, she confirmed that she would have been expected the care plan to be updated accordingly. Review of Resident 46's clinical record revealed diagnoses that included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident 46's current physician's orders on May 8, 2023, revealed a physician's order for a regular diet, soft to chew texture, regular/thin consistency, no straws, and food cut into small bite sized pieces, with a start date of March 31, 2023. Review of Resident 46's care plan revealed a care plan for: Potential risk for altered nutritional status related to end stage dementia. This care plan had an intervention of: use a lid and straw when drinking liquids, with a start date of March 31, 2023. Interview with the NHA on May 10, 2023, at 6:14 PM, revealed that the physician's order was correct, and that Resident 46 was not supposed to be using straws and the care plan should have been changed to reflect that. Review of Resident 55's clinical record revealed diagnoses that included chronic kidney disease (long-standing disease of the kidneys leading to renal failure-a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Resident 55's physician orders revealed the following order: Dialysis treatment per schedule, with a discontinued date of March 6, 2023. Review of Resident 55's care plan revealed a care plan problem for potential for dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) related to renal failure (condition in which the kidneys lose the ability to remove waste and balance fluids) with hemodialysis (a treatment to filter wastes and water from one's blood as the kidneys would do when they were healthy); history of urinary tract infections and septicemia (a life-threatening complication of an infection that occurs when the chemicals released by the body into the blood stream to fight an infection trigger inflammation throughout the body); needs encouraged to hydrate, with a goal date of May 1, 2023. During an interview with the NHA and DON on May 10, 2023, at 2:40 PM, the concern of Resident 55's potential for dehydration care plan problem not being revised to indicate a history of hemodialysis under for further review and follow-up. Email communication received from NHA on May 10, 2023, at 6:18 PM, indicated that Resident 55's care plan was changed to say renal failure with history of dialysis. During an interview with the NHA on May 11, 2023, at 9:45 AM, she confirmed that she would have been expected the care plan to be updated accordingly. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food in a safe and sanitary manner in the main dietary kitchen and in two of three nourishment pantries (Main dietary kitchen, Fellowship Place Pantry, and Family Place Pantry). Findings include: Review of facility policy, titled Food Storage, last reviewed July 13, 2022, revealed the policy stated At times food may be opened from its original storage container but not used - these unused food items may be returned to storage if completely wrapped or placed in appropriate storage container with lid to prevent infestation. These products must be labeled with the date opened and what the item is if not readily apparent .Any food items with a manufacturers expiration date must be used prior to expiration date or discarded on expiration date .Prepared foods that have not been used must be discarded if not used within 72 hours. Observation in the Main dietary kitchen on May 8, 2023, at approximately 6:45 PM, revealed multiple potatoes on a baking pan located on the lower shelf of a preparation table. The preparation table was located between the Main dietary kitchen's walk-in freezer and walk-in refrigerator. Observations of the potatoes revealed that they were not labeled or dated. Observations in the Main dietary kitchen on May 9th, 2023, at approximately 11:10 AM, revealed the potatoes were still stored in the same location. Observations of the Family Place Pantry area on May 8, 2023, at approximately 7:00 PM, revealed the following: one container of mandarin oranges, one container of fruit mix, and one container of cocktail sauce that were beyond the identified expiration date; one container of pears, one pan of cake, one bag of apples, and one bag of bagels that did not have an opened date; multi-colored cereal stored in a plastic, zip-closure bag with no label or date written on the bag; and one container of a brown powdered substance, with a smell consistent with cinnamon, that had no label or date. It was also observed that oranges were stored in a bag labeled chicken, which had an expiration date of June 25, 2022, written on the bag. Further observations of the Family Place Pantry area revealed multiple staff personal items were stored in a drawer in the pantry area. Items observed included a staff water bottle, sweatshirt, hair brush, and fragrance spray. Observation of the refrigerator in the Fellowship Pantry area on May 8th, 2023, at approximately 7:15 PM, revealed one container of butter and one container of creamer that were open but not dated. Observations of a freezer unit revealed two zip-close bags of what appeared to be chicken, that was not labeled or dated. During a staff interview on May 11, 2023, at approximately 11:00 AM, Nursing Home Administrator (NHA) revealed it was the facility's expectation that food items are labeled and dated. During the staff interview, NHA revealed that staff personal items are not to be stored in the pantry area, and that the facility has designated areas for staff to store their personal items. 28 Pa code 211.6(f) Dietary services