Based on facility policy review, observations, review of select facility documentation, and resident and staff interviews, it was determined that the facility failed to maintain a clean, comfortable and home-like environment in one of 35 resident rooms reviewed. Findings include: Review of facility policy, titled Resident Rights Under Federal Law last revised February 1, 2023, read, in part, The resident has a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Interview with Resident 368 on April 27, 2025, at 12:29 PM, revealed he was disappointed about the condition of the wallpaper in his bathroom, and it had been that was since he was admitted to the room on April 21, 2025. Observation in Resident 368's bathroom on April 27, 2025, at 12:32 PM, revealed the wallpaper was coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. Interview with the Nursing Home Administrator (NHA) on April 29, 2025, at 2:11 PM, revealed it is the responsibility of staff to identify environmental concerns in resident rooms on a daily basis to be communicated to maintenance staff to be fixed. Review of facility maintenance work order report from April 22-29, 2025, failed to reveal an active work order in place for Resident 368's bathroom. Follow-up observation in Resident 368's bathroom on April 30, 2025, at 10:20 AM, revealed the wallpaper remained in the same condition as it was on April 27, 2025; coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. During an interview with the NHA on April 30, 2025, at 11:44 AM, she revealed she would speak with Employee 4 (Maintenance Director) to address the issues in Resident 368's bathroom. She further revealed they have hired a third maintenance employee whose sole responsibility will be identifying and fixing physical issues such as the wallpaper around the facility. Follow-up interview with the NHA on April 30, 2025, at 1:32 PM, revealed Employee 4 is currently addressing the concerns in Resident 368's bathroom, and she would expect residents to be provided with a clean, comfortable and home-like environment 28 Pa. Code 201.18(b)(3) Management

Based on clinical record reviews 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 35 residents reviewed (Residents 48 and 82). Findings include: Review of Resident 48's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), and difficulty walking. Review of Resident 48's clinical record revealed that he had experienced a fall with no injuries on January 24, 2025. Review of Resident 48's Medicare Quarterly/5 Day 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) with the assessment reference date (last day of the assessment period) of January 30, 2025, indicated in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on January 17, 2025. During a staff interview with Employee 2 (Registered Nurse Assessment Coordinator) on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 48's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 48. Review of Resident 82's clinical record revealed diagnoses that included muscle weakness, difficulty walking, and history of a traumatic brain injury (an injury to the brain caused by an external force). Review of Resident 82's clinical record revealed that he had experienced a fall with an injury on February 8, 2025, and was sent to the emergency room for evaluation of the injury. Review of Resident 82's Discharge Return Anticipated MDS with the assessment reference date of February 9, 2025, revealed in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on February 2, 2025. During a staff interview with Employee 2 on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 82's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the NHA and the DON on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 82. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of 38 residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed diagnoses that included congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and atrial fibrillation (irregular heart beat). Review of Resident 84's physician order summary revealed an order for daily weights and to notify the doctor of a gain of 2 pounds or greater in a day or 5 pounds in a week for congestive heart failure, starting February 17, 2025. Review of Resident 84's daily weight documentation revealed that no weights, or refusals to be weighed, were documented for eight days in February 2025; for 15 days in March 2025; and for three days in April 2025. Further review of Resident 84's weight documentation revealed that a weight of 176.1 pounds was recorded on April 24, 2025, and that a weight of 187.8 pounds was recorded on April 25, 2025. This represented a weight gain of 11.7 pounds in one day. Review of Resident 84's clinical record failed to reveal that the practitioner was notified of this change in weight or that a reweigh was obtained. During an interview with the Director of Nursing on April 30, 2025, at 2:28 PM, she revealed the expectation that Resident 84's daily weights should have been recorded, and that follow-up should have occurred when a weight gain was recorded on April 25, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, observations, product label, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Findings include: Review of facility policy, titled Food Brought in for Patients/Residents last revised January 26, 2024, read, in part, Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. Food will be held in refrigerator for three days following the date on the label and will be discarded by staff upon notification to resident. Observation in Reach-in Refrigerator 1 on April 27, 2025, at 9:52 AM, revealed one container of thickened lemon water open and not dated with an open date; and one container of thickened lemon water open with an open date of April 2, 2025. Further observation of the thickened beverage containers read After opening, may be kept up to 7 days under refrigeration. Observation in the Station II Pantry Area on April 27, 2025, at 10:28 AM, revealed one thickened apple juice open with an open date of April 18, 2025. Interview with Employee 3 (Food Service Director) on April 27, 2025, at 10:28 AM, revealed that container should have been discarded after seven days. Observation in the Medbridge Pantry Area on April 27, 2025, at 10:30 AM, revealed one thickened lemon water open and not dated with an open date; and one container of food from an outside source not dated. Observation in the Arcadia Pantry Area on April 27, 2025, at 10:32 AM, revealed a box of food from an outside source dated April 21, 2025; one container of thickened apple juice open and not dated with an open date; one thickened lemon water open and not dated with an open date; one thickened lemon water open with an open date of March 25, 2025; one pudding prepared for medication pass with a use by date of April 26, 2025; and one bag of food from an outside source not dated. Interview with Employee 3 on April 27, 2025, at 10:33 AM, revealed the beverages should have been labeled properly and discarded after seven days of being open; and refrigerated food from outside sources should be labeled properly and discarded after three days. Interview with the Nursing Home Administrator on April 28, 2025, at 1:32 PM, revealed it was the facility's expectation that expired items are discarded, foods items and beverages are labeled and dated per facility policy, and food items and beverages are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.12(d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review as well as resident and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 36 residents reviewed (Residents 12, 52 and 80). Findings include: Review of Resident 12's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel resulting in too much sugar circulating in the bloodstream). During an interview with Resident 12 on May 5, 2024, at 11:04 AM she revealed that she has tooth pain due to poor dentition and needs to have several teeth removed. Review of the dental consult dated August 16, 2023, revealed that Resident 12's teeth, #22-#26, are broken and unrestorable. Review of Resident 12's dental consult dated January 15, 2024, revealed that the same teeth remain broken. Review of speech therapy evaluation dated December 5, 2023, revealed that Resident 12 had teeth that were observed to be black and rotted to the gumline. Review of Resident 12's January 13, 2024 comprehensive annual 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) revealed that the assessment was not coded to indicate that Resident 12 had obvious or likely cavity or broken natural teeth. During an interview with Employees 1 (Registered Nurse Assessment Coordinator) and 2 (Clinical Reimbursement Coordinator) on May 8, 2024, at 1:51 PM they revealed that Resident 12's January 13, 2024, MDS was completed by an off-site staff person who did not visualize Resident 12's dentition, but coded the assessment based on an admission/re-admission evaluation completed by nursing staff on January 10, 2024, which indicated that Resident 12 had dentures, but no other dental concerns. Review of Resident 52's clinical record revealed diagnoses including dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and type 2 diabetes (decrease ability of the body to utilize insulin for the transport of glucose from the blood into the cells for nourishment). Review of Resident 52's clinical record revealed that Resident 52 was admitted to the facility on [DATE]. After admission, on February 28, 2024, facility staff identified a pressure injury to Resident 52's right heel that presented as a fluid filled blister measuring 5.0 centimeters (cm - metric unit of measure) by 5.0 cm. On March 6, 2024, a progress note stated that Resident 52's blister had opened with visible wound base. Review of wound tracking for Resident 52's pressure injury revealed the wound base developed slough (yellow/white accumulation of dead cells that usually presents as soft and wet but can be dry) on March 27, 2024 and necrotic skin (eschar - brown to black hard area of dead skin/tissue) was present upon an April 4, 2024 assessment. Review of the wound tracking revealed that Resident 52's pressure injury continued to have varying amounts of necrotic skin during assessments conducted on April 11, 19, 26, 2024, and May 3, 2024. Review of Resident 52's Discharge Return Anticipated Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) with an assessment reference date of April 14, 2024, revealed that Section M Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, was coded to reflect that Resident 52 had an Unstageable - Slough and/or eschar pressure injury, and that the pressure injury was present upon admission or reentry to the facility. Review of Resident 52's Quarterly MDS with an assessment reference date of April 20, 2024, revealed that section K, subsection K0300 Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in the last 6 month, was answered as Yes, not on prescribed weight-loss regimen. However, review of Resident 52's weight documentation during the look back of 30 days (or closest) and 180 days (or closest) revealed Resident 52 did not have a weight loss of 5% in 30 days nor 10% in 6 months. Further review of the Quarterly MDS revealed that section M - Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage, subsection G1, was coded to reflect that Resident 52 had one unstageable deep tissue injury (purple or maroon area of discolored intact skin due to damage of the underlying soft tissue). Finally, the pressure ulcer coded under section M of the Quarterly MDS was identified as present upon admission or reentry, however; the pressure injury was sustained after Resident 52 had entered the facility. Review of aforementioned wound tracking revealed that, at the time of the Quarterly MDS with assessment reference date of April 20, 2024, Resident 52's pressure injury was acquired at the facility and presented with necrotic tissue/eschar and was not considered a deep tissue injury at that time. During a staff interview on May 8, 2024, at approximately 3:05 PM, the Director of Nursing confirmed that Resident 52's Discharge Return Anticipated MDS section M and Quarterly MDS section K and section M were coded incorrectly. During the staff interview the Director of Nursing revealed corrections were being made to the MDS errors identified. Review of Resident 80's clinical record on May 7, 2024, at 11:52 AM, revealed diagnoses that included epileptic seizures (a sudden alteration of behavior due to a temporary change in the electrical functioning in the brain) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 80's physician orders revealed Resident 80 was admitted to hospice services December 12, 2022. Review of Resident 80's minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 80 was receiving hospice services while a resident for two quarterly MDS assessments with dates of September 20, 2023 and March 18, 2024 and one annual MDS assessment dated [DATE]. During an interview on May 7, 2024, at 2:04 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor made the NHA and DON aware of the aforementioned MDS concerns. During an additional interview on May 8, 2024, at 1:15 PM, with the NHA and DON it was revealed that Resident 80's two quarterly and one annual MDS assessments where coded incorrectly and corrections had been completed. The DON stated that it was the facility's expectation that MDS assessments be completed accurately. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for three of 6 residents reviewed for pressure ulcers (Residents 11, 72 and 110). Findings Include: Review of policy, Wound Dressings: Aseptic, revised December 1, 2021, revealed that following application of a wound treatment, staff should document the treatment on the Treatment Administration Record (TAR- form used to document physician orders as well as when and how treatments are administered to a resident). Review of Resident 11's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. Review of nursing progress note dated March 14, 2024, revealed that staff discovered an open area at the top of Resident 11's sacrum on that date. Review of a skin integrity report revealed that Resident 11's open area was classified as a stage III pressure injury (involves the full thickness of the skin and may extend into the subcutaneous tissue layer). Review of Resident 11's March 2024 TAR revealed an order to cleanse the sacrum with saline solution, apply skin prep (liquid that forms a protective film or barrier) to the peri wound (skin around the wound), let dry, apply hydrogel to the wound bed (creates moist environment to promote healing) and cover with a dry dressing every evening shift. This order was effective March 16, 2024. Further review of Resident 11's March 2024 TAR revealed that it was not documented that this treatment was completed on March 18, 22, and 25, 2024. Review of Resident 11's May 2024 TAR revealed an order to cleanse the sacrum with wound cleanser and apply a wet to dry dressing each evening shift, effective April 29, 2024. Further review revealed that this treatment was not documented as being completed on May 3, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:41 PM, she acknowledged the missing documentation and revealed the expectation that treatments should be documented. Review of Resident 72's clinical record revealed diagnoses that included dementia and moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of nursing progress note dated April 30, 2024, revealed Resident 72 had stage III pressure injuries on his left heel, right heel, and right ankle. Review of Resident 72's April 2024 TAR revealed an order to cleanse the left heel with wound cleanser, apply skinprep to the periwound, apply hydrogel to the wound bed, and cover with an optifoam dressing (has a silicone border, waterproof backing and high absorbency) on day shift every Tuesday and Friday, effective April 12, 2024. Further review revealed that it was not documented that this treatment was completed on April 19, 2024. Resident 72's April 2024 also contained an order, effective April 5, 2024, to cleanse the right heel with wound cleanser, apply hydrogel to the wound bed, and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. Lastly, Resident 72's April 2024 TAR revealed an order, effective April 5, 2024, to cleanse the right lateral ankle with wound cleanser, apply therahoney (wound filler made of 100% medical grade Manuka honey that promotes healing and reduces odor) to the wound base and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM, she revealed that she had no additional information, and stated she would expect that wound treatments would be documented. Review of Resident 110's clinical record revealed diagnoses that included: pressure ulcer of left heel (wound that occurs due to prolonged pressure), peripheral vascular disease (a disorder of the blood vessels outside the heart), and muscle weakness. Review of Resident 110's November 2023 TAR revealed a physician order for, Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's November 2023 TAR failed to reveal documentation that this treatment was completed on November 22 day shift and November 27 evening shift. Review of Resident 110's December 2023 TAR revealed a physician order for, Treatment: Buttocks: cleanse with soap and water, pat dry, apply Hydraguard (blue top tube) every shift and as needed, with a start date of December 20, 2023, and a discontinued date of January 3, 2024. Further review of Resident 110's December 2023 TAR failed to reveal documentation that this treatment was completed on December 23 night shift and December 29 day shift. Review of Resident 110's January 2024 TAR revealed a physician order for, Treatment: Buttocks: cleanse with normal saline solution, apply hydrogel to wound base and cover with Opti foam every evening shift, with a start date of January 4, 2023, and a discontinued date of January 26, 2024; and a physician order for Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's January 2024 TAR failed to reveal documentation that the aforementioned treatments were completed on January 5 and 8 evening shifts. Review of Resident 110's February 2024 TAR revealed a physician order for, Treatment: sacrum: cleanse with normal saline solution, Apply wet to dry dressing to wound bed, cover with ABD pad and secure with tape. Apply Hydraguard (blue top tube) to periwound every day and evening shift, with a start date of February 2, 2024, and a discontinued date of March 1, 2024. Further review of Resident 110's February 2024 TAR failed to reveal documentation that this treatment was completed on February 10 day and evening shifts. Review of Resident 110's May 2024 TAR revealed a physician order for, Treatment bilateral buttocks: Cleanse with soap and water, pat dry, Apply a thin layer of Zguard and cover with Nystatin Powder to every day and evening shift for wound care, with a start date of April 19, 2024. Further review of Resident 110's May 2024 TAR failed to reveal documentation that this treatment was completed on May 3 evening shift. Email correspondence with the DON on May 7, 2024, at 5:21 PM, revealed she was unable to provide additional information for Resident 110's missing TAR documentation. During a follow-up interview with the DON on May 8, 2024, at 12:54 PM, she revealed she would expect wound treatments to be documented as completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on policy review, observation, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 32 residents reviewed (Resident 36). Findings include: Review of the facility policy titled Procedure: Nebulizer: Small Volume, last reviewed April 23, 2024, stated 21. Rinse SVN, mouthpiece, and T piece with sterile water and dry and 21.1 Place in treatment bag labeled with patient name and date. 21.2 Replace and date the setup daily, if used. Review of Resident 36's clinical record revealed diagnoses that included pulmonary embolism (blood clot in the lungs) with acute pulmonale (right-sided heart failure caused by an issue with the lungs) and chronic obstructive pulmonary disease (condition involving constriction of the airways causing difficulty breathing). Review of Resident 36's physician orders revealed an order for Ipratropium-Albuterol Solution (medication used to treat and prevent symptoms caused by ongoing lung disease) 0.5-2.5 (3) MG/3ML one application inhale orally four times a day for cough and one vial inhale orally every four hours as needed for cough. Review of Resident 36's April 2024 and May 2024 Medication Administration Record (MAR- documentation of medications administered) revealed Resident 36 received Ipratropium-Albuterol every four hours (9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM) daily. An observation on May 6, 2024 at 10:37 AM, revealed the nebulizer mask lying uncovered on Resident 36's nightstand. The medication reservoir was still attached to the mask and clear liquid droplets were visualized in the reservoir. The attached tubing was dated April 4. Resident 36 stated she receives the nebulizer treatment four times a day and that staff use to clean it and change the mask frequently, but they don't anymore. An additional observation was made May 7, 2024, at 10:39 AM, of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated April 4. During a staff interview with Employee 4 (Registered Nurse) on May 7, 2024, at 10:43 AM, it was revealed that nebulizer tubing is to be changed weekly by respiratory therapy. During a staff interview in Resident 36's room with Employee 5 (Respiratory Therapist) on May 7, 2024, at 10:56 AM, the surveyor informed Employee 5 of the aforementioned observations. Employee 5 revealed that she started here recently was waiting on a list of nebulizers in the building. Prior to her starting nursing was responsible for tubing changes. Employee 5 stated she changes oxygen tubing weekly and cleans filters and is planning to change nebulizer tubing weekly with the oxygen tubing changes. Employee 5 also revealed nebulizer masks are to be cleaned after each treatment and all should be bagged when not in use. Employee 5 stated was going to replace the nebulizer mask and tubing and get a bag to store it in when not in use. During an additional interview with Resident 36 on May 7, 2024, at 1:30 PM, she reported her nebulizer mask and tubing had been replaced. Resident 36 also revealed she received nebulizer treatment at 1:00 PM but staff never came back to remove it, so she had to do it herself and no one had cleaned the mask after the treatment. An observation was made of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated May 7. During a staff interview on May 7, 2024, at 1:56 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON) the surveyor made them aware of the multiple observations of Resident 36's nebulizer mask and tubing and of Resident 36's statement that staff do not clean the mask and reservoir after administering the treatment. 28 Pa code 211.12(d)(1)(2)(3) Nursing Services

Based on review of the review of clinical records, and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 32 residents reviewed (Resident 107). Findings include: A review of the clinical record for Resident 107 on May 6, 2024, revealed diagnoses that include neurogenic bladder (lack of bladder control due to spinal cord problem and nerve problem) and spina bifida (a birth defect when the developing baby's spinal cord fails to develop properly). A review of Resident 107's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 20, 2024, revealed that the resident had a brief interview for mental status with a score of 15, indicating Resident 107 is cognitively intact. Further review of Resident R107's clinical records revealed, and he had moisture associated skin damage (MASD) on his buttock and scrotum and was ordered to have a thin layer of zinc paste applied every shift. Observation during wound care on May 7, 2024, revealed zinc paste was observed prior to the start of the observation and was applied post wound care. During an interview with Resident 107 on May 6, 2024, Resident 107 confirmed that he was receiving treatments every shift for both his chronic wounds and some white paste (referring to zinc paste was confirmed) to protect his buttock and scrotal area from damage. The resident also confirmed that he was receiving Ketoconazole cream 2% (treatment for skin condition, dermatitis) applied to his head, face, and neck to prevent dry, flaky skin every shift. A review of Resident 107's Treatment Administration Record (TAR) on May 7, 2024, revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the Ketoconazole cream 2% on April 8, 2024, on dayshift, April 11, 2024, on dayshift, and on April 14, 2024, on evening shift. Further review of Resident 107's TAR revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the zinc past on April 5, 2024, on evening shift, April 7, 2024, on night shift, and April 14, 2024, on evening shift. During an interview with the Director of Nursing (DON) on May 8, 2024, at approximately 2:27 PM, the DON confirmed that all treatments should be signed off as completed on the TAR. 28 Pa Code 211.5(f) Medical records. 28 Pa Code 211.12(d)(1) Nursing services.

Based on facility policy review, record review, and staff and resident interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for two of 4 residents reviewed for nutritional status (Residents 60 and 72). Findings include: Review of facility policy titled Procedure: Weights and Heights last revised February 1, 2023, read, in part, A licensed nurse or designee will weigh the patient. If the body weight is not as expected, re-weigh the patient. Review of Resident 60's clinical record revealed diagnoses that included: muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). During an interview with Resident 60 on May 5, 2024, at 9:58 AM, he revealed he had lost a lot of weight at the facility. Further review of Resident 60's physician orders revealed an order for a weight every month with a start date of November 30, 2023, that was discontinued on November 30, 2023, noting the reason to be Resident on [nurse aide] task to weigh each month the 1st-7th. Review of Resident 60's weight measures revealed he had an unplanned weight loss of 8.6 pounds (4.9%) from March 4, 2024, to his next weight measure on April 11, 2024. Further review of Resident 60's weight measures failed to reveal monthly weight measures for November 2023, and January 2024; and failed to reveal a re-weigh was obtained for the weight change on April 11, 2024. Review of Resident 60's clinical record failed to reveal a nutrition assessment between the dates of March 22, 2024, and April 26, 2024. During an interview with the Director of Nursing on May 8, 2024, at 1:02 PM, she revealed she has identified problems with weight orders and weight monitoring at the facility; she revealed Resident 60 should have had a monthly weight obtained in November, and should have had an order in place and a monthly weight obtained in January; furthermore, she revealed she would expect him to have a re-weigh for his weight measure on April 11, 2024, and a nutrition assessment in response to his weight loss prior to two weeks later. Review of Resident 72's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of Resident 72's recorded weights revealed he experienced an unplanned significant weight loss of 16 pounds (approximately a 10% loss) between March 9, 2024, and April 2, 2024. Review of a dietician progress note dated April 3, 2024, revealed that this weight loss was noted and reviewed. Further review revealed instructions to monitor weekly weights due to the significant weight change. Review of Resident 72's clinical record failed to reveal that weekly weights were obtained or recorded between April 2, 2024, and May 1, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM she revealed the expectation that weekly weights should have been obtained as recommended by the dietician following Resident 72's significant weight loss. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior for three of four nursing units observed (Stations 1, 2, and 3). Findings include: Observations made on February 20, 2024, at the noted times and locations revealed the following: - 9:03 AM in the dining room outside of the main kitchen (corner of Station 1 and 2) - the air vent was noted to be covered in a black, speckled substance. - 9:32 AM in Resident 1's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:37 AM in Resident 2's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:41 AM in the Station 3 lounge - presence of a black substance on the grates of the wall heating/cooling unit. - 9:42 AM in Resident 3's room (Station 3) - the wall above the heating/cooling unit appeared to be crumbling with debris noted in and on the heating/cooling unit. - 9:44 AM in Resident 4's room (Station 3) - the plastic grate was missing from the heating/cooling unit. Food and other debris were noted in the unit. - 9:45 AM in Resident 5's room (Station 3) - dried spill/splash spots on the front grill panel of the heating/cooling unit. Food and other debris were observed inside of the unit. A black substance was present on the air vent grates. - 9:47 AM in Resident 6's room (Station 3) - an accumulation of debris was noted in the heating/cooling unit. Additionally, the air vent grates were noted to be soiled. - 9:57 AM in Resident 7's room (Station 2) - a black substance was present in the corner near the heating unit vent. - 9:59 AM in the Chapel Dining Room (located at the corner of Station 1 and 2) - black film on the wall around the vent/heating unit. - 10:01 AM in Resident 8's room (Station 1) - a black substance was present along the seam of the wallpaper in the corner near the heating unit. During a tour with the Nursing Home Administrator and Director of Nursing (DON) on February 20, 2024, at 10:30 AM, they acknowledged the aforementioned concerns. During a later interview with the DON on February 20, 2024, at 1:33 PM, she revealed that work orders had been submitted to have required repairs completed, and staff were in the process of going room to room to audit for cleanliness. 28 Pa. Code 201.14(a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and interview, it was determined the facility failed to ensure individuality and respect of resident personal property for one of three residents reviewed (Resident R2). Findings include: A review of the facility policy titled, Patient's Personal Property, last reviewed and revised [DATE], states, Personnel will identify and record the patient's/resident's (hereinafter patient) belongings upon admission to a Center. To protect the patient's right to retain their personal belongings and preserve the patient's individuality and dignity. In the event of the patient's discharge or death, valuables or other assets in the Center's possession will be secured until the appointed personal representative of the patient's estate presents a copy of the certified Letter of Administration to the Center. A review of the clinical record revealed that Resident 2 has resided at the facility since her most recent admission on [DATE]. Further review of the record revealed that Resident 2 passed away at the facility on [DATE]. Based on the written correspondence to the Department of Health on [DATE], from Resident 2's personal representative, when the family arrived to obtain the personal belongings of Resident 2 on [DATE], they were handed a closed box. Upon reviewing the items there were many items missing that included under ware, coloring books, colored pencils, pocketbook, wallet, and jewelry. During an interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 PM, the NHA stated that housekeeping emptied the residents personal belongings from the resident's room into a box. The NHA also stated that housekeeping staff admitted to discarding the coloring books, pencils, and under ware. The NHA stated that she remains in contact with Resident 2's representative for any additional items that are reported missing. The facility was requested to provide the personal property inventory list for Resident 2 and the NHA admitted that no personal inventory list for Resident 2 could be located. The NHA also stated that she has changed the policy so that in the future personal items of the deceased are secured in the social workers office until they are picked up by family. 28 Pa. Code 201.18(b)(2)Management.

Based on review of select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for one of three residents reviewed (Resident 49). Findings include: Review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on June 13, 2023, revealed that Medicare coverage for Resident 49 started on January 4, 2023, and that Resident 49's last covered day was February 16, 2023. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the Resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide form CMS-10055, SNF ABN (Advanced Beneficiary Notice - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) to the Resident or the Resident's Representative as required at the time that Medicare Part A was discontinued. On June 15, 2023, at 10:11 AM, the Nursing Home Administrator (NHA) stated that form CMS-10055 was not one of the forms that was presented to Resident 49. On June 15, 2023, at 10:21 AM, NHA stated that form CMS-10055 has been sent to the social workers to start using immediately. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide a notice of transfer for two of nine residents reviewed for hospitalization (Residents 42 and 60). Findings include: Review of Resident 42's clinical record on June 12, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 42's clinical record revealed that on February 21, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a notice of transfer. Review of Resident 42's clinical record revealed that on March 1, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a notice of transfer, nor was there notification of the transfer sent to a Representative of the State Ombudsman for the transfer on March 1, 2023. Review of Resident 60's clinical record on June 13, 2023, at approximately 10:00 AM, revealed diagnoses including diabetes mellitus type 2 and quadriplegia (partial or full loss of function in both arms and both legs). Review of Resident 60's clinical record revealed that Resident 60 was transferred to a hospital emergency room after a change in condition on February 8, 2023, and March 21, 2023. Review of available documention revealed that no transfer notice was provided to Resident 60 and/or Resident 60's Representative for neither the February 8, 2023, and March 21, 2023, transfers. During a staff interview on June 15, 2023, at approximately 12:30 PM, Director of Nursing revealed that, prior to May 1, 2023, transfer notices were not consistently provided in response to resident transfers to a hospital. 28 Pa. code 201.14(a) Responsibility of licensee

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident and/or resident representative received written notice of the facility bed-hold policy at the time of transfer for three of nine residents reviewed for hospitalization (Residents 42, 106, and 123). Findings Include: Review of facility policy and process, titled Bed Hold Notice - Deliver Upon Transfer, last revised August 2022, revealed section titled, Process stated, Bed hold notification is required per Federal regulation [Title 42, Chapter IV, Subchapter G, Part 483.15(d)(2)]. To meet Federal and survey requirements, Genesis follows Accounts Receivable Policy 102 Bed Holds, which states: Prior to a resident transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and representative, if applicable, with the Bed Hold Policy Notice & Authorization form (Smartworks form # GHC-4731) .Notice must be given regardless of payer .Resident copy is given directly to the resident prior to transfer and noted in the medical record .Representative copy can be delivered electronically via email/secure fax or hard copy via mail if the representative is not present at the time of transfer. (Must be done within 24 hours.) Review of Resident 42's clinical record on June 12, 2023, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 42's clinical record revealed that on March 1, 2023, Resident 42 was transferred to a hospital emergency after a change in condition. Review of available documentation from the facility revealed that the facility did not provide Resident 42 and/or Resident 42's Representative with a copy of the facility's bed-hold policy in response to the hospital transfer. During a staff interview on June 15, 2023, at approximately 12:30 PM, Director of Nursing (DON) revealed that the facility had identified multiple concerns with required documents being provided upon transfer in regards to resident transfers that took place prior to May 1, 2023. During a staff interview on June 15, 2023, at approximately 1:45 PM, Nursing Home Administrator (NHA) revealed that the facility had no further information to provide regarding a bed-hold notice being provided to Resident 42 in response to the hospital transfer on March 1, 2023. A review of Resident 106's clinical record on June 13, 2023, revealed diagnoses that included hypertension (elevated blood pressure) and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of Resident 106's clinical record revealed that Resident 106 was transferred to the hospital on April 18, 2023, and returned to the facility on May 1, 2023. During an interview with the NHA and DON on June 15, 2023, at approximately 10:51 AM, the NHA indicated that she could not provide a copy of the bed-hold notice for Resident 106's hospitalization. The NHA further indicated that bed-hold notices were not being rendered prior to her assuming the role of NHA on May 1, 2023. Review of Resident 123's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and chronic combined systolic and diastolic heart failure (heart failure in which the heart cannot pump [systolic] or fill [diastolic] properly). Review of clinical record further revealed that Resident 123 was transferred to the hospital on April 17, 2023, and returned to the facility on April 20, 2023. Resident 123 was again transferred to the hospital on April 26, 2023, and returned to the facility on May 1, 2023. During an interview with the NHA and DON on June 15, 2023, at approximately 10:51 AM, the NHA indicated that she could not provide a copy of the bed-hold notices for Resident 123's hospitalizations. She further indicated that bed-hold notices were not being rendered prior to her assuming the role of NHA on May 1, 2023. 28 Pa. Code 201.14(a) Responsibility of Licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for two of 29 residents reviewed (Residents 93 and 126). Findings include: Review of Resident 93's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and difficulty in walking. Review of nursing progress note dated June 11, 2023, revealed that Resident 93 obtained a skin tear to her left lower leg on this date. Further review revealed that it was documented that Resident 93 was to begin wearing leg protectors at all times, except for during care. Review of nursing progress note dated June 12, 2023, revealed that a skin tear was discovered on the back of Resident 93's right calf. It was again noted that the intervention to prevent future occurances was for Resident 93 to wear leg protectors. Observations on June 12, 2023, at 1:20 PM; June 13, 2023, at 12:39; and on June 14, 2023, at 1:20 PM, revealed that Resident 93 was not wearing leg protectors. During an interview with the Director of Nursing (DON) on June 15, 2023, at 12:46 PM, she revealed the she was unable to locate two padded leg protectors, so another type of sleeve was used in the meantime. She also revealed the expectation that Resident 93 should have been wearing some kind of leg protectors. Review of Resident 93's occupational therapy Discharge summary dated [DATE], revealed that she was seen and treated by occupational therapy for wheelchair positioning. Further review revealed, upon discharge from services, it was noted that Resident 93 was utilizing assistive devices, including leg rests, to maintain proper wheelchair positioning. Review of Resident 93's care plan revealed that she was to be using leg rests on her wheelchair, effective February 10, 2023. Observations of Resident 93 on June 12, 2023, at 1:20 PM; June 13, 2023, at 12:39; and on June 14, 2023, at 1:20 PM, revealed her in her wheelchair. Resident 93 was slouched in her chair, with the back of her neck resting on the top of the back of her wheelchair. No leg rests were present on Resident 93's wheelchair. During an interview with the DON on June 15, 2023, at 12:49 PM, she revealed the expectation that Resident 93 should have had leg rests on her wheelchair. Review of Resident 126's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Review of a practitioner progress note dated May 4, 2023, indicated that Resident 126 was seen on that date. It was noted that the Resident had a low grade temperature of 99.5 degrees. Further review revealed that the practitioner noted a plan to complete a urinalysis (test to examine the urine contents for any abnormalities that indicate a disease condition or infection). Review of a physician order form dated May 4, 2023, revealed an order for urinalysis with culture and sensitivity (a test to identify bacteria and their antibiotic susceptibility). The form was signed by both the practitioner and nurse. Review of a nursing progress note dated May 7, 2023, revealed that a urine sample was successfully obtained on May 6, 2023. Review of Resident 126's clinical record failed to indicate any documentation of the results of the urinalysis. During an interview with the DON on June 15, 2023, at 12:43 PM, she revealed that, when she called the laboratory for the results of the urinalysis, she was informed that the lab did not have them. The DON revealed that she was unable to provide any information about what happened to the urine sample. She revealed the expectation that someone should have caught this and followed-up. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and interviews with resident and staff, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed (Resident 123). Findings include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) Communication and Documentation with a last revision date of June 15, 2022, revealed, in part: Center staff will communicate with the certified dialysis center regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments; prior to leaving the facility a licensed nurse will complete the top portion of the Hemodialysis Communication Record and send with the patient to his/her HD facility visit; and upon return of the patient to the facility, a licensed nurse will review the dialysis center communication, evaluate the resident, and complete the post-hemodialysis treatment section of the Hemodialysis Communication Record; and maintain the Hemodialysis Communication Record in the patient's medical record. Review of Resident 123's clinical record revealed diagnoses that included end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for long-term dialysis or a kidney transplant) and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 123's current physician orders included Hemodialysis per physician order, with a start date of May 22, 2023; and Dialysis site observation-left upper arm every shift and as needed, dated May 22, 2023. During an interview with Resident 123 on June 13, 2023, at 9:08 AM, Resident 123 revealed that they currently attend dialysis on Mondays, Wednesdays, and Fridays. During this interview, it was observed that Resident 123 had a dialysis catheter to their right chest. Review of Resident 123's dialysis communication book located at the nurses' station revealed the presence of only one completed facility Hemodialysis Communication Form, which was dated June 7, 2023. There were, however, computer generated communication sheets from the dialysis center, except for June 9, 2023. Review of Resident 123's clinical record progress notes revealed that they did attend dialysis on June 9, 2023. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 15, 2023, at 10:58 AM, the NHA confirmed that the staff should have been completing the Hemodialysis Communication Form consistently as per facility policy. She further indicated that they had ordered more forms and will be educating staff. During an interview with the NHA and DON on June 15, 2023, at 1:01 PM, the DON confirmed that she would expect Resident 123's order to be accurate in regards to their hemodialysis catheter site location for proper monitoring. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of the sign-in sheets for the facility's quarterly Quality Assurance (QA) Committee and staff interview, it was determined that the required members failed to attend one out of three quarterly meetings since the last Full Health Survey cleared date of September 1, 2022. Findings include: Review of the QA Committee sign-in sheets revealed that the facility Infection Preventionist was not in attendance at the January 18, 2023, meeting. During an interview with Nursing Home Administrator (NHA) on June 15, 2023, at approximately 10:23 AM, the NHA confirmed that the Infection Preventionist was not at the meeting, and revealed the expectation that all required members should attend meetings quarterly. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.18(e)(3) Management

Based on observation and staff interview, it was determined that the facility failed to ensure that informational postings located throughout the facility contained all pertinent state agency and resident advocacy contact information. Findings include: Observation on June 15, 2023, at 12:32 PM, revealed the informational postings present throughout the facility did not contain the following required information: correct contact phone number for the State Survey Agency, mailing and email addresses of the State Survey Agency, nor contact information (name, phone number, mailing and email addresses) for the State Long-Term Care Ombudsman program, for adult protective services, for the home and community-based service programs, for the protection and advocacy network agency, or for the Medicaid Fraud Control unit. During an interview with the Nursing Home Administrator on June 15, 2023, at 1:48 PM, she acknowledged that the postings were not accurate or complete. 28 Pa. Code 201.29(i) Resident rights

Based on observations and resident family and staff interviews, it was determined that the facility failed to maintain a safe, clean comfortable, and home-like interior on four of six units observed (Arcadia, A Hall, B Hall, and D Hall). Findings include: Observations on the Arcadia unit revealed the following: - On June 12, 2023, at 10:20 AM, armchairs present in front of the nursing station had an accumulation of dried debris and liquid present on the sides and rungs of the chairs. - On June 12, 2023, at 11:08 AM, large, dried liquid rings were present on the couch located in the unit lounge. Additionally, two wheelchairs (one with cushions and leg rests stored in the seat of the chair), two walkers, and a chair scale were stored in the lounge. The lounge was being utilized for visitation with Resident 125 at the time of the observation. - On June 12, 2023, at 11:11 AM, Resident 117 was observed standing in the parlor. The lights were off in the room. Two wheelchairs and two mechanical lifts were being stored in the room at the time. - On June 13, 2023, at 12:36 PM, the stains remained present on the lounge couch. Two wheelchairs were stored in the lounge. In the parlor, it was observed that two mechanical lifts, one wheelchair, an overbed table, and wheelchair legs were being stored. In the dining room, it was observed that multiple dining chairs had an accumulation of dried debris and liquid on the sides and rungs of the chairs. - On June 14, 2023, at 12:28 PM, two mechanical lifts, a chair scale, and one wheelchair were stored in the lounge. The stains remained present on the lounge couch. In the parlor, it was observed that two wheelchairs, wheelchair legs, a mechanical lift, and an overbed table were being stored. A staff person was sitting with Resident 86 in the parlor at the time of the observation. At 12:41 PM on that date, it was observed that Resident 125 was served his lunch in the parlor. - On June 15, 2023, at 10:25 AM, it was observed that lifts and a wheelchair were still stored in the lounge and the parlor. The couch in the lounge remained stained. Chairs present in the dining room were observed to have an accumulation of dried debris and liquid on the sides and rungs of the chairs. During an interview with a family member of Resident 125 on June 12, 2023, at 12:08 PM, she revealed a concern with the cleanliness of the lounge and the furniture in the lounge. Additionally, she expressed a concern with the amount of items stored in the lounge, noting that Resident 125 often mistakes the wheelchair (stacked with cushions and leg rests) for a car. Observations of A Hall Unit revealed the following: - On June 12, 2023, at 12:14 PM, a mechanical stand-aide lift was observed in Resident 81's room near their bed, impeding their access to sit beside the bed in their wheelchair. Resident 81 was observed attempting to maneuver their wheelchair around the lift when Employee 6 intervened. - On June 13, 2023, at 8:56 AM, it was observed in the lounge that a mechanical lift, a chair scale, two broda chairs, and three wheelchairs were being stored. -On June 14, 2023, at 9:16 AM, it was observed in the lounge that three wheelchairs and a chair scale were being stored. -On June 14, 2023, at 1:00 PM, it was observed in Resident 81's room that a mechanical stand-aide lift was stored at the foot of their roommates bed. Observation of B Hall Unit revealed on June 13, 2023, at 8:58 AM, revealed that a mechanical lift was being stored in the lounge. Observation of D Hall Unit on June 14, 2023, at 9:14 AM, revealed that four mechanical lifts and one broda chair were being stored in the lounge. Findings of all observations were shared with the Nursing Home Administrator (NHA) and Director of Nursing on June 14, 2023, at 2:03 PM, for further follow-up. During an interview with the NHA on June 15, 2023, at 12:58 PM, she acknowledged the aforementioned concerns. She revealed that the furniture that could not be cleaned would be disposed of. She also revealed that she identified storage concerns upon her arrival at the facility, and that she plans to work on finding additonal storage and educating staff on where to store things. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on observations, staff interviews, and clinical record review, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised to reflect the resident's current status for eight of 29 residents reviewed, (Residents 30, 72, 81, 83, 86, 106, 118, and 125). Findings include: Review of Resident 30's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic pain. Review of Resident 30's care plan revealed that she was to be out of bed for all meals, effective February 10, 2023. Observation on June 12, 2023, at 12:38 PM, and June 13, 2023, at 12:42 PM, revealed Resident 30 eating her meal in bed. During an interview with the Director of Nursing (DON) on June 15, 2023, at 1:45 PM, she revealed that the intervention for Resident 30 to be out of bed for all meals was no longer applicable since she has had a decline in functioning since that time. She confirmed that the care plan was not accurate. Review of nursing progress notes and physician orders revealed that Resident 30 was admitted to hospice services (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness)on March 3, 2023, for dementia and kidney disease. Review of Resident 30's current care plan failed to reveal that it was noted that Resident 30 was receiving hospice services. During an additional interview with the DON on June 15, 2023, at 1:25 PM, she acknowledged that hospice should have been on Resident 30's plan of care. She provided an updated care plan. A review of the clinical record for Resident 72 on June 12, 2023, at 1:00 PM, revealed diagnoses that included congestive heart failure (CHF-excessive body/lung fluid caused by a weakened heart) and chronic obstructive pulmonary disease (COPD- disease process that causes decreased ability of the lungs to perform). Observation of Resident 72 on June 12, 2023, at 10:30 AM, revealed oxygen was being administered at 2 liters per minute (lpm) via nasal cannula (NC). A review of Resident 72's physician orders dated June 2023 revealed oxygen to be administered at 2 lpm via NC every shift for shortness of breath. A review of Resident 72's care plan on June 13, 2023, failed to include a care plan for oxygen administration. During an interview with the DON on June 14, 2023, the DON confirmed Resident 72's care plan should have been revised to include oxygen administration. Review of Resident 81's clinical record revealed diagnoses that included anxiety and hypertension. Review of Resident 81's current physician orders revealed the following orders: Apply right thumb brace after AM care. Check skin integrity prior to application every day shift, dated March 2, 2023; and remove right thumb brace at HS (bedtime). Check skin integrity after removal at bedtime, dated March 1, 2023. Review of Resident 81's care plan revealed that the use of thumb brace was not included as part of their care plan. During an interview with the Nursing Home Administrator (NHA) and DON on June 15, 2023, at 10:56 AM, the DON confirmed that the brace was not mentioned on Resident 81's care plan and that she would have expected it to be on the care plan. She further indicated that she had updated the Resident's care plan to include the brace. A review of the clinical record for Resident 83 on June 12, 2023, at 1:00 PM, revealed diagnoses that included schizophrenia (mental disease characterized by loss of reality contact, delusions, hallucinations, and/or feelings of persecution) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of the clinical record for Resident 83 on June 12, 2023, at 1:00 PM, revealed the diagnosis of schizophrenia was added to the Resident's diagnoses list on August 17, 2022. A review of Resident 83's care plan dated June 2023, failed to include a focus area, goals, or interventions for the diagnosis of schizophrenia. During an interview with the DON on June 14, 2023, the DON confirmed Resident 83's care plan should have been revised to include the diagnosis of schizophrenia. Review of Resident 86's clinical record revealed diagnoses that included dementia with agitation and psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions). Review of Resident 86's current care plan revealed active plans of care for a laceration (deep cut) to the back of the head, effective December 26, 2022. Review of nursing progress notes dated January 1, 2023, indicated that staples were removed from Resident 86's head at that time. Review of physician orders revealed that treatment orders for the laceration/staples were discontinued on January 6, 2023. During an interview with the DON on June 15, 2023, at 12:43 PM, she revealed that she resolved the care plan associated with a head laceration. A review of the clinical record for Resident 106 on June 12, 2023, at 1:00 PM, revealed diagnoses that included diabetes mellitus (DM- a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and schizophrenia. Observation of Resident 106 on June 12, 2023, at 11:00 AM, revealed oxygen was being administered at 3 lpm via NC. A review of Resident 106's physician orders dated June 2023, revealed oxygen to be administered at 3 lpm via NC every shift for shortness of breath. A review of Resident 106's care plan dated June 2023, on June 13, 2023, failed to include a care plan for oxygen administration. During an interview with the DON on June 14, 2023, the DON confirmed the care plan for oxygen therapy should be developed. Review of Resident 118's clinical record revealed diagnoses that included hypertension and personal history of COVID-19. Review of Resident 118's current care plan revealed a care plan focus for: Has/At risk for respiratory impairment related to + COVID, with a date initiated of December 2, 2022, with a goal target date of September 6, 2023. During an interview with the NHA and DON on June 15, 2023, at 1:01 PM, the DON confirmed that Resident 118 did not have an active COVID-19 infection and that that the care plan should have been revised when their infection resolved in December 2022. Review of Resident 125's clinical record revealed diagnoses that included dementia with agitation and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 125's nursing progress notes revealed the following: - May 6, 2023 - Resident was noted to be swearing at staff and residents, swinging at other residents. - May 15, 2023 - Resident was verbally aggressive with staff and residents, attempting to hit staff and other residents. - May 17, 2023 - Resident picked up chair and threw it. - May 18, 2023 - Resident was using profanity. - May 20, 2023 - Resident was verbally and physically aggressive. - May 22, 2023 - Resident was noted to be agitated, beating on closed doors, attempting to leave the secured unit, grabbed staff person and put hand around their neck, swinging fists, cursing, pinching. Resident was sent to the emergency department on this date for evaluation due to behavioral concerns. - May 23, 2023 - Resident was swearing and was agitated. - May 25, 2023 - Resident was noted to be agitated. - May 26, 2023 - Resident was using profanity - May 27, 2023 - Resident hit staff with his wheelchair, was attempting to hit/bite staff, using profanity. - May 29, 2023 - Resident was noted to be hitting his head on the wall. Further review of Resident 125's progress notes indicated that he was being followed by psychiatric services for mood and agitation concerns. Review of Resident 125's current care plan failed to reveal notation of specific behavioral concerns or personalized non-pharmacological interventions to manage the aforementioned behavioral concerns. During an interview with the DON on June 15, 2023, at approximately 12:45 PM, she acknowledged that care plan accuracy was an issue that she identified at the facility upon her arrival, and that the facility is currently working through a process improvement plan to address the concern. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plans 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for four of five nurse aides reviewed (Employee 1, 2, 3, and 5), and failed to ensure that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 1, 2, 3, 4, and 5). Findings Include: Review of select facility documentation revealed that Employee 1 was hired on October 15, 2016 ; Employee 2 was hired on September 25, 2005; Employee 3 was hired on December 2, 2021; Employee 4 was hired on August 31, 1998; and Employee 5 was hired on June 1, 2022. During an interview with the Nursing Home Administrator on June 15, 2023, at 2:40 PM, she confirmed that Employee 4's performance evaluation was the only one able to be found, and she confirmed that she could not provide any documentation of completed education for all Employees selected for review. She further indicated this was due to the change in ownership in January. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 125). Findings include: Review of facility policy, titled Medication Regimen Review revised March 3, 2020, revealed that the consultant pharmacist will conduct medication regimen reviews (MRRs) and make recommendations based on the information available in the resident's health record. Copies of residents' MRRs will be provided to the Director of Nursing (DON) and/or the attending physician and to the Medical Director. The facility will then encourage the physician/prescriber or other responsible parties to act upon the recommendations contained in the MRR. For the issues requiring intervention, the practitioner/prescriber should accept and act upon the recommendations, or reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected. The attending practitioner should document in the residents' health records that the identified irregularity was reviewed and what, if any, action was taken to address it. If the attending physician decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Review of Resident 125's clinical record revealed diagnoses that included severe dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Further review of Resident 125's clinical record revealed that medication regimen reviews were completed on April 12, 2023, May 11, 2023, and on May 19, 2023. Irregularities were noted by the consultant pharmacist, and recommendations were made on those dates. Additional review failed to reveal what recommendations were made or the physician's response to these recommendations. During an interview with the DON on June 15, 2023, at 1:46 PM, she revealed that she did not have any additional information to provide. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident medication regimen was free from unnecessary psychotropic medication as evidenced by failure to monitor for target behaviors and/or adverse side effects for six of 26 residents reviewed (Residents 30, 86, 102, 118, 125, and 126), and for failure to act upon a physician's order to reduce a psychotropic medication in a timely manner for one of 26 residents reviewed (Resident 126). Findings include: Review of Resident 30's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions). Review of Resident 30's current physician orders revealed orders for Fluoxetine (antidepressant) twice a day for depression, effective January 21, 2023; and Seroquel (antipsychotic medication) for psychotic disorder in the morning, effective May 10, 2022, and at bedtime, effective May 9, 2022. Review of Resident 30's clinical record failed to reveal that behavior monitoring was in place to track or document behaviors related to depression or psychosis. During an interview with the Director of Nursing (DON) on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done. Review of Resident 86's clinical record revealed diagnoses that included Alzheimer's disease and psychotic disorder. Review of Resident 86's current physician orders revealed orders for Ativan (antianxiety medication) as needed for anxiety (sense of uneasiness, distress, or dread), effective June 7, 2023; Rexulti (antipsychotic medication) daily for dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), effective June 10, 2023; Depakote (anticonvulsant also used to treat certain psychiatric disorders) twice a day and at bedtime for delusional disorder (unshakable belief in something that's untrue), effective October 2, 2021; Paxil (antidepressant) daily for adjustment disorder (difficulty in managing stressful life changes), effective December 11, 2021; and buspirone (antianxiety medication) every eight hours for anxiety, effective June 9, 2023. Review of Resident 86's clinical record failed to reveal that behavior monitoring was in place to track or document behaviors related to anxiety, delusional disorder, dementia with agitation, or adjustment disorder. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done, and that it was added to Resident 86's orders for Depakote and Rexulti. Review of Resident 102's clinical record on June 12, 2023, at approximately 12:30 PM, revealed diagnoses including diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the transfer of glucose from the blood stream into the cells for nourishment) and obsessive compulsive disorder (OCD - mental health disorder characterized by obsessive thoughts that contribute to compulsive often repetitive behaviors). Review of Resident 102's physician orders on June 13, 2023, at approximately 1:30 PM, revealed a physician order for fluvoxamine maleate (psychotropic medication used to treat obsessive compulsive disorder), 50 milligrams once a day at bedtime with the identified indication of hoarding (chronic and persistent inability to discard/part with possessions because of a pervasive perception that the items need to be saved). Review of Resident 102's clinical record revealed no behavior monitoring was in place to monitor Resident 102's behavior of hoarding or any other behavior associated with Resident 102's OCD. During a staff interview on June 15, 2023, DON confirmed that there was no behavior monitoring in place for Resident 102 at that time. Review of 118's clinical record revealed diagnoses that included depression and adjustment disorder with anxiety (an emotional or behavioral reaction to a stressful event or a change in a person's life with symptoms that may include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed). Review of 118's current physician orders revealed the following orders: busPIRone HCl Tablet (an antianxiety medication) 30 MG Give one tablet by mouth two times a day for anxiety, dated August 8, 2022; and Lexapro oral tablet (antidepressant medication) 10 MG (escitalopram oxalate) Give 10 milligrams by mouth one time a day for Depression, dated April 21, 2023. Review of Resident 118's care plan revealed the following care plan focus items: 1) Resistive/noncompliant with treatment/care (refusing showers) related to: Belief that treatment is not needed/working, Cognitive Impairment, with date initiated of February 20, 2023, and last revision date of June 13, 2023; 2) At risk for changes in mood related to diagnosis of adjustment disorder with mixed anxiety, with date initiated of August 3, 2022, and last revision date of June 13, 2023; and 3) At risk for adverse effects related to adjustment disorder: use of antianxiety/depression medication, with date initiated of August 2, 2023, and last revision date of June 13, 2023. Further review of Resident 118's clinical record failed to reveal documentation of monitoring of their identified target behaviors or documentation of medication side effect monitoring. During an interview with the Nursing Home Administrator and DON on June 15, 2023, at 12:38 PM, the DON confirmed that there was no documentation that they could provide for Resident 118's identified target behavior monitoring or medication side effect monitoring. She indicated that she is updating orders for psychotropic medications to include Resident specific target behaviors to monitor for as well as appropriate side effect monitoring. Review of Resident 125's clinical record revealed diagnoses that included Alzheimer's disease and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 125's current physician orders revealed orders for Rexulti daily for dementia with aggression, effective June 5, 2023; olanzapine (antipsychotic medication) at bedtime for severe dementia with agitation, effective May 26, 2023; and Citalopram (antidepressant) daily for depression, effective April 7, 2023. Review of Resident 125's clinical record failed to reveal evidence of behavior monitor for behaviors related to dementia with aggression/agitation or depression. Further review also failed to reveal monitoring for adverse medication side effects. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior/side effect monitoring was not being done. Review of Resident 126's clinical record revealed diagnoses that included severe dementia with agitation, and alcohol induced persisting amnestic disorder (disorder of the central nervous system characterized by amnesia and memory deficits caused by a deficiency of thiamine [vitamin B1] in the brain typically associated with prolonged, excessive ingestion of alcohol). Review of Resident 126's current physician orders revealed orders for Haldol (antipsychotic medication) every eight hours for dementia with agitation, effective May 19, 2023; Quetiapine (antipsychotic) three times a day for dementia with behavioral disturbance, effective May 25, 2023; and Trazadone (antidepressant) at bedtime for depression, effective May 3, 2023. Review of Resident 126's clinical record failed to reveal evidence of behavior monitoring for behaviors related to dementia with agitation or depression. During an interview with the DON on June 15, 2023, at 12:33 PM, she acknowledged that behavior monitoring was not being done, and that it was added to Resident 126's orders for Haldol and quetiapine. Review of Resident 126's medical practitioner progress note dated May 15, 2023, revealed, On exam he is noted to have some decreased range of motion in neck. Patient denies pain, he is on Haldol. Discussed with PGS [geropsychiatric service provider] for concerns of dystonia [movement disorder that causes the muscles to contract involuntarily causing repetitive or twisting movements - can be a potential medication side effect]. Will decrease Haldol to 1.5 mg PO [by mouth] TID [three times a day]. Review of physician order form dated May 15, 2023, revealed a written order to decrease Resident 126's Haldol to 1.5 mg every eight hours. The order form was signed by the practitioner and nurse. Review of geropsychiatric medical practitioner progress note dated May 19, 2023, revealed, CRNP [Certified Registered Nurse Practitioner] expressed concerns r/t [related to] possible dystonia vs [versus] neuroleptic malignant syndrome [rare but life-threatening reaction that can occur in response to neuroleptic or antipsychotic medication] on 5/15. Reported pt [patient] to have increasing temperatures 99.5, skin flush/red, neck stiffness, he was able to rotate head left/right, unable to flex neck. Discussed reduction of Haldol and increase of Cogentin [used to treat symptoms of involuntary movements due to the side effects of certain psychiatric drugs] for 7 days. After review of MAR [Medication Administration Record] Haldol was not reduced. Further review of this progress noted indicated a plan to reduce Haldol to 1.5 mg every eight hours as previously noted. Review of physician order dated May 19, 2023, revealed a second written order to decrease Haldol to 1.5 mg three times per day. The order form was signed by the practitioner and nurse. Review of Resident 126's May 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that it was documented that Resident 126 continued to receive the higher dose of Haldol through May 19, 2023, at 1:00 PM. During an interview with the DON on June 15, 2023, at 12:42 PM, she confirmed that the order to reduce Resident 126's Haldol was not completed and carried out in a timely manner. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of resident fund statements, and staff interview, it was determined that the facility failed to close residents' financial accounts within 30 days after discharge or death for three of four residents reviewed (Residents 6, 7, and 8). Findings include: Review of Resident 6's clinical record revealed that Resident 6's date of death was January 18, 2023, and that at least a balance of $6648.99 remained in the Resident fund account as of April 18, 2023. Review of Resident 7's clinical record revealed that Resident 7's date of death was March 2, 2023, and that at least a balance of $8353.37 remained in the Resident fund account as of April 18, 2023. Review of Resident 8's clinical record revealed that Resident 8's date of death was February 10, 2023, and that at least a balance of $5758.15 remained in the Resident fund account as of April 18, 2023. During an interview with the Nursing Home Administrator on April 18, 2023, at approximately 2:40 PM, she acknowledged that the aforementioned funds were not distributed to the responsible party as required within 30 days of discharge. 28 Pa. Code 201.18(b)(2)(e)(1) Management

Based on observation and staff interview, it was determined that the facility failed to ensure a safe, clean, comfortable, and homelike interior on one of six nursing hallways (Arcadia). Findings include: Observation on March 8, 2023, at 10:30 AM, on the Arcadia unit revealed several pieces of white paperlike debris under the bench in the hallway outside of the dining room. Observation also revealed multiple pieces of debris, including string, dust balls, and paperlike scraps on the floor in the parlor. Observation on March 8, 2023, at 2:00 PM, revealed the same debris was present under the bench and in the parlor. During an interview with the Nursing Home Administrator on March 9, 2023, at 12:30 PM, he revealed that there was a Housekeeper assigned to the unit all day on March 8, 2023, and that the missed areas were an oversight on the Housekeeper's part. 28 Pa. Code 207.2(a) Administrator's responsibility

Based on clinical record review, observations, as well as resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of three residents reviewed for showers (Residents 1 and 2). Findings include: Review of Resident 1's clinical record revealed diagnoses that included muscle weakness and abnormalities of gait and mobility. During an interview with Resident 1 on March 8, 2023, at 10:00 AM, she revealed that she did not get her shower on two recent occasions because the staff told her they didn't have time. She also revealed that on one of those occasions she did receive a bed bath, but that she does not feel as clean afterwards as when she receives a shower. Review of a shower documentation revealed that Resident 1 is scheduled to receive a shower on Mondays and Thursdays on the day shift. Review of shower documentation revealed that it was not documented that Resident 1 received a shower on February 20, 2023, and received a bed bath instead of a shower on March 2, 2023. No refusals were noted. Review of Resident 2's clinical record revealed diagnoses that included muscle wasting and atrophy and difficulty in walking. During an interview with Resident 2 on March 8, 2023, at 10:03 AM, she indicated that she does not always receive her shower when scheduled. Review of a shower documentation revealed that Resident 2 is scheduled to receive a shower on Mondays and Thursdays on the evening shift. Review of shower documentation revealed that it was not documented that Resident 2 received a shower February 13, 2023, and March 6, 2023. No refusals were noted. During an interview with the Nursing Home Administrator on March 9, 2023 at 12:30 PM, he revealed that he had no additional information as to why Residents 1 and 2 did not receive their showers as noted above. He also revealed that staff are being educated to not use staffing as an excuse not to give showers. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that newly hired staff had the required orientation, competencies, and skill sets required for their position for two of two employees reviewed (Employees 1 and 2). Findings include: Review of job description Unit Manager, revised January 2016, revealed the following job summary: The Unit Manager oversees the care management of a population of patients within an assigned area, unit or clinical function. The position conducts the nursing process - assessment, planning, implementation, and evaluation - under the scope of the State's Nurse Practice Act of Registered Nurse licensure. The position coordinates resource utilization, timely and appropriate care interventions, and interdisciplinary communication to enhance patient and family satisfaction, adherence to center's clinical system and regulatory compliance. Review of job description Nurse Supervisor, revised June 2018, revealed the following job summary: Supervises nursing personnel to deliver nursing care and within scope of practice coordinates care delivery, which will ensure that patient's needs are met in accordance with professional standards of practice through physician orders, center policies and procedures, and federal, state, and local guidelines. Currently licensed as an LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] or RN [Registered Nurse]. During an interview with Employee 1 (Registered Nurse) on March 8, 2023, at 10:30 AM, she revealed that she does not feel that she was properly oriented to her position as Unit Manager. She also revealed that she is expected to function as Nurse Supervisor at times, but does not feel she received sufficient training to perform the required duties. Additionally, she revealed that she does not recall completing any skills competencies when she was hired. Review of signed job description Unit Manager, revealed that Employee 1 was hired on November 18, 2022. Review of job description Quality Assurance/Staff Development/Infection Preventionist RN, dated October 2021, revealed the following job summary: Acts as center's resource for quality systems, clinical practice guidelines, speciality programs, regulations and enforcement, and clinical safe business practices. Responsible to assess the training needs of nursing staff and to develop, implement, evaluation and document staff development programs including General Orientation, Job Specific Orientation, In-Service, and Continuing Education Programs for nursing department personnel. Functions within the scope of the state's Nurse Practice Act for R.N. licensure. A registered licensed nurse designated to act as the coordinator of an infection prevention and control program to oversee the general application of the infection control guidelines. During an interview with Employee 2 on March 8, 2023, at 10:45 AM, she revealed that she started on December 15, 2022. Employee further revealed that she feels she did not receive sufficient training to perform her required duties as Quality Assurance/Staff Development/Infection Preventionist RN. During an interview with the Nursing Home Administrator on March 9, 2023, at 1:18 PM, he revealed that he was not able to provide any additional documentation of orientation, training, or competency evaluations for either Employee 1 or 2 other than the training certificate Employee 2 obtained from the CDC (The Centers for Disease Control and Prevention) for nursing home infection Preventionist training course. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.20(b) Staff development

Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure that equipment was in safe operating condition for two of two crash carts observed (Station 1 and Station 3 carts). Findings include: Review of facility policy, titled Emergency Cart, revised December 1, 2021, revealed, The emergency cart is checked every 24 hours and after each use. During an interview with Employee 1 (Registered Nurse) on March 8, 2023, at 10:30 AM, Employee 1 stated the concern that facility crash carts (maintained with equipment used in cardiac emergencies) are not being checked as often as they should be. Observation on March 8, 2023, at 11:45 AM, revealed a crash cart located near Station 1 nursing desk. Further observation revealed a clip board on the cart containing daily crash cart signature logs. Instructions on the log indicated that using the emergency cart checklist, staff is to verify all required equipment is located on the cart and that the breakaway locks securing the drawers are intact and unchanged from the previous day. A review of these logs from January 1, 2023, to March 8, 2023, revealed no signature indicating the cart was checked January 2023: 1-16, 18, 20-21, 23; February 2023: 1-10, 13-27; and March 2023: 1-7. Observation on March 8, 2023, at approximately 1:00 PM, revealed a crash cart located near Station 3 nursing desk. Further observation revealed a clip board on the cart containing daily crash cart signature logs. A review of these logs from January 1, 2023, to March 8, 2023, revealed no signature indicating the cart was checked on January 2023: 10, 14-15, 24; and February 2023: 7, 21, 25-27. During an interview with the Nursing Home Administrator on March 8, 2023, at 3:23 PM, he confirmed that the Unit Manager or Registered Nurse Supervisor would be the parties responsible for checking the crash carts. He also revealed the expectation that staff would follow the current policy. 28 Pa Code: 201.14(a) Responsibility of licensee