**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews it was determined that the facility failed to ensure the residents code status for one out of 24 residents reviewed (Resident 173). Findings include: Review of the clinical record revealed the resident was admitted to the facility on [DATE]. Further review revealed that the resident was sent to the hospital on November 25, 2023 for new symptoms of Congested Heart Failure (CHF-Heart does not pump blood effectively). The resident was readmitted to the facility on [DATE]. Review of Resident 173's clinical record revealed a POLST (Pennsylvania -Orders for Life Sustaining Treatment) was signed on November 3, 2023, stating the resident was a Do Not Resuscitate (DNR). Review of the physician orders revealed the DNR was not current. Interview with the Director of Nursing on December 7, 2023 at 9:40 a.m. revealed when the resident went to the hospital all physician orders were discontinued. Further interview revealed upon readmission of resident resident, on November 30, the DNR order was not restarted. The facility failed to ensure the resident's right to formulate an advance directive for Resident 173. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy and procedure, observation, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure infection control and prevention was implemented during a COVID-19 outbreak on two of two units observed (First and Second Floor Unit). Findings include: Review of facility policy and procedure titled Response to an Outbreak of COVID-19, revised November 20, 2023, revealed Identification of a single new case (resident or staff) 14 days after the last known case would meet the criteria for a new outbreak and prompt the need for an outbreak response. Further review of this policy revealed Managing exposed residents and employees as part of the unit-based or facility-wide response: Employees working in COVID rooms/areas must wear full PPE, including a full-face shield (goggles are not acceptable) gown, gloves and N-95. Further review of this policy revealed For full outbreak, on day 1-10, staff caring for residents in the yellow zone should use full PPE (gloves, gowns, eye protection using a full-face shield, and N-95. The facility experienced a COVID-19 outbreak beginning on November 20, 2023 and continuing through December 7, 2023. This outbreak consisted of a total of thirty-three (33) residents. Interview with Nursing Home Administrator and Director of Nursing on December 4, 2023, at 9:00 a.m. revealed that all staff and visitors must wear full PPE (personal protective equipment) on both the first floor and second floor nursing units due to the COVID-19 outbreak. This interview further revealed that staff were to remove PPE prior to leaving a COVID-19 positive resident's room and wash the face shield for reuse. Observation on December 4, 2023, at 11:17 a.m. on the second-floor nursing unit revealed a dietary aide preparing meal trays with a face shield pulled to the top of the staff person's head. Observation on December 4, 2023, at 11:24 a.m. on the second-floor nursing unit revealed Employee E4 exit a COVID-19 positive resident room and enter a resident room with COVID-19 negative residents without changing any PPE. This observation further revealed Employee E4 exit the COVID-19 negative room, remove the PPE gown and walk up the hallway to dispose of the gown without donning another gown. Observation on December 4, 2023, at 11:27 a.m. revealed Physical Therapist Employee E5 exit a COVID-19 positive resident room without removing PPE and walked in the hallway to the elevator area and removed the PPE at the elevator area. Observation on December 4, 2023, at 11:33 a.m. on the second-floor nursing unit revealed housekeeping Employee E7 remove PPE gown after cleaning a COVID-19 positive room, don a new gown at the housekeeping cart without washing hands or face shield. Housekeeping Employee E7 returned to the housekeeping cart and proceeded to continue to empty trash in the spa room without washing hands and/or washing face shield or changing mask or face shield. Observation on December 4, 2023, at 12:04 p.m. in the second-floor elevator revealed CNA Employee E6 enter the elevator wearing a gown and proceed to the first floor and exit the elevator on the first floor wearing the PPE gown that was worn on the second floor. Interview with CNA Employee E6 revealed employee was going to lunch. Observation on December 5, 2023, at 8:54 a.m. revealed facility physician sitting at the nurses' station desk wearing N-95 mask and goggles but no face shield. Observation on December 5, 2023, at 11:38 a.m. revealed a visitor at the second-floor elevator entrance preparing to exit the unit wearing a surgical mask and no other PPE, Visitor stated I didn't know there was COVID here. Observation on December 5, 2023, at 11:42 a.m. revealed a staff member returning from lunch; walked to the nurses' station in a surgical mask, no N-95 mask and no face shield. Employee donned N95 at the nurses' station. Observation on December 5, 2023, at 11:49 a.m. revealed staff member arrive on the second-floor nursing unit with no PPE Staff person entered the assisted dining room with no PPE then walked down the hall to the linen cart for a gown; re-entered the assisted dining room with mask and gown but no face shield. Staff person then exited the assisted dining room and walked down a second hallway and returned to the dining room without wearing the required face shield. Observation on December 5, 2023, at 11:55 a.m. revealed a staff person assisting a resident to eat in the assisted dining room without wearing the required face shield. Observation on all days of the survey revealed donning and doffing of all PPE occurring in the same location at the entrance to the second-floor elevator area. Interview with Licensed Employee E8, infection preventionist on December 6, 2023, at 1:30 p.m. revealed the facility was aware of breaches in infection control protocol due to low staffing. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 7, 2023, at 10:00 a.m. Review of Resident 53's clinical records revealed resident tested positive for COVID (An infectious disease caused by a virus named SARS-CoV-2) on November 26, 2023, and was on contact isolation (Used when a patient has an infectious disease that may be spread by touching either the patient or other objects that patient has handled). In addition to standard precautions Observation of Resident 53's door revealed signage indicating as follows: For all staff - Contact and Droplet Precaution in addition to standard precautions. The same signage also revealed Before entering the room, perform hand hygiene, put on a gown, put on a mask, put on protective eyewear, perform hand hygiene, and put on gloves. On leaving the room, dispose of gloves, dispose of gown, perform hand hygiene, remove protective eyewear, dispose of the mask, and perform hand hygiene. Observation was conducted on December 4, 2023, at 12:08 p.m of meal service. Unlicensed employee E3 was observed entering Resident 53's room with a gown, mask, and face shield. Employee E3 assisted the resident with setting up meals and touching the resident and the table. Employee E3 was observed leaving Resident 53's room and then went to assist another resident who was negative for COVID without changing their gown and performing hand hygiene. Employee E3 was observed leaving the room and assisted two other residents on the same unit without changing gowns. At 12:14 p.m., Employee E3 was observed leaving the C- Unit with the same gown then came back at 12:16 p.m. and proceeded to assist two other residents. Interview with Employee E3 was conducted on December 4, 2023, at 12:18 p.m. Employee E3 confirmed not changing PPE (Personal Protective Equipment) after assisting Resident 53, a positive COVID resident before leaving the room and assisting other residents who were negative for COVID. Employee E3 stated, I forgot [resident name] was COVID-positive. The above information was discussed with the Nursing Home Administrator on December 7, 2023, at 9:45 a.m. The facility failed to ensure, that infection control and prevention were practiced on the First floor Unit. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 2/10/23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 2/10/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, interview, and clinical record review, it was determined the facility failed to provide toileting services as requested to one resident resulting in a fall for one of seven residents reviewed (Resident 53). Findings include: Review of facility policy and procedure titled Fall Management Program, reviewed August 25, 2022, revealed Risk Assessment - formal/documented assessment tool that identifies those residents at risk and the degree that they are at risk by assessing past history and present condition; assessments done on admission, readmission, quarterly, and when there is a significant change in condition. Further review of this policy and procedure revealed Preventative measures/interventions - decrease environmental risks, obstacles and clutter. Further review of this policy and procedure revealed Post fall investigation/guidelines/management: toilet schedule; review of bowel/bladder patterns. Review of Resident 53's admission Falls Risk assessment dated [DATE], revealed a score of 11 indicating Resident 53 was at risk for falls. Review of Resident 53's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated September 29, 2022, revealed Resident 53 required the extensive assistance of one staff member for toileting. Further review of Resident 53's admission MDS revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating cognitive impairment. Review of Resident 53's current plan of care revealed Resident 53 was at risk for falls and family was to notify the facility when leaving after visiting. Interview with Resident 53's family member on January 31, 2023, at 2:00 p.m. revealed on Thursday, November 24, 2022, after visiting with Resident 53, family member notified staff that she was leaving the facility and that Resident 53 needed to be toileted. The staff member indicated to the family member that they were leaving in 15 minutes. This interview further revealed that shortly after leaving the facility family member received a phone call that Resident 53 had fallen and was being sent to the hospital. Review of Resident 53's progress notes dated November 24, 2022, revealed found on floor of bathroom. Left leg is painful and she is unable to move it. Provider notified and gave orders to send to ER [acute care facility] for eval.[evaluation] POA [power of attorney] updated. Further review of Resident 53's progress notes dated November 29, 2022, revealed Resident arrived to room [ROOM NUMBER] in stable condition from [acute care facility]. [Resident] had an ORIF [open reduction internal fixation] of [resident] left femur [large bone located in upper leg]. Interview with the Nursing Home Administrator and Director of Nursing on February 3, 2022, at approximately 1:00 p.m. revealed the facility was not always able to promptly address toileting needs and the assumption was that Resident 53 toileted himself/herself due to his/her lack of safety awareness. The facility failed to ensure Resident 53 was toileted as requested, requiring Resident 53 to attempt to toilet himself/herself resulting in a fall in the bathroom which resulted in a fractured femur requiring surgery for repair. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely address a significant weight loss for one of eight residents reviewed (Resident 56). Findings include: Review of facility policy, Weight Monitoring Protocol, reviewed October 5, 2022, indicated that if significant unplanned weight loss of 5% in one month or 10% in six months, the following steps are taken: a. Nursing will reweigh the resident to check accuracy the next day but no more than 48 hours, b. If weight is accurate, notify the physician, c. Residents with significant weight changes will be weighed weekly for 4 weeks and referred for dietician monitoring, d. POA/Responsible Party to be notified of significant weight changes, e. Care plan to be updated as needed. Review of Resident 56's clinical record revealed a weight of 110.1 pounds on November 3, 2022. Weight and reweight recorded on December 6, 2022, was 98.5 pounds (loss of 11.6 pounds or 10.5%. Review of nursing progress note of December 13, 2022, indicated weight noted. Further review of the clinical record revealed weekly weights were not obtained and the next weight obtained was 101.9 pounds on December 30, 2022. Review of Weight Loss Monitoring Note of December 30, 2022, indicated ongoing weight loss and recommended resident be weighed weekly for four weeks. Follow up weights were obtained on January 3, 2023 of 97.4 pounds, January 17, 2023 of 97.5 pounds, and February 1, 2023 of 95.0 pounds. Interview with Employee E3 on February 3, 2023, at 10:30 a.m. revealed that the dietitian was not aware of the significant weight loss and confirmed weekly weights should have been initiated at that time. Employee E3 also confirmed that weekly weights were obtained consistently after the recommendation on December 30, 2022. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review, it was determined that the facility failed to provide education regarding the COVID-19 vaccine to resident and/or resident representatives prior to receiving/declining the COVID-19 vaccination for one of 24 residents reviewed (Resident 43). Findings include: Review of Resident 43's clinical record failed to reveal evidence that education regarding the COVID-19 vaccination was provided to Resident 43 or Resident 43's representative prior to Resident 43's representative declining the vaccination. Interview with the Nursing Home Administrator and Director of Nursing on February 3, 2023 at 1:00 p.m. failed to produce evidence that Resident 43 and/or their representative were provided educational material regarding the COVID-19 vaccination prior to Resident 43 and/or their representative declining the vaccination. 28 Pa. Code 201.18(a)(b)(1) Management

Based upon observation and resident and staff interviews, it was determined that the facility failed to protect resident rights regarding visitation. Findings include: Observation of signage at the facility entrance on January 18, 2022 at 9:30 a.m. revealed that the facility was denying visitation to residents due to a GI (gastrointestinal) virus. The signage further revealed that review of the visitation closing would be held on January 18, 2022. Observation of signage at the facility entrance on January 18, 2022 at 2:30 p.m. revealed that the closing of visitation would continue until January 20, 2022 at which time another review would be held. Observation of meals on January 18, January 19, and January 20, 2022 revealed all residents ate meals in their rooms with no residents being permitted to eat in any of the dining rooms in the facility. Interview with the Nursing Home Administrator during Entrance Conference on January 18, 2022 at 10:00 a.m. revealed that the facility had stopped visitation to residents on December 28, 2021 due to an unidentified GI virus. Review of the facility's Outbreak Case - Patient Line List revealed that one resident had symptoms of vomiting on December 27, 2021 and one resident had symptoms of vomiting on December 28, 2021. Further review of the Line List revealed one staff person had symptoms on December 27, 2021, one staff person had symptoms on December 30, 2021 and one staff person had symptoms on December 31, 2021. Further review of the Patient Line List revealed four specimens were sent to the state laboratory for testing. Review of a laboratory test result dated January 11, 2022 revealed one resident tested positive for norovirus (GI virus). The sample was obtained January 11, 2022 and resulted January 18, 2022. Interview with the Nursing Home Administrator on January 19, 2022 at 1:00 p.m. revealed that at the virus peak, six residents on one unit on the second floor of the facility had exhibited signs and symptoms of the virus. Interview with Resident 28 on January 19, 2022 at 12:23 p.m. revealed Resident 28 tearful related to the restriction of visitation. Further interview with Resident 28 revealed Resident R28 was to have a meeting with spouse, financial advisor and her son but that she was informed she would not be able to attend due to visitation restrictions. Resident 28 further revealed residents were restricted to their rooms and not allowed to visit with other residents on the same floor/unit/hallway, in the facility. Interview with Resident 36 on January 19, 2022 at 11:30 a.m. revealed Resident 36 was to be discharged to Personal Care on January 17, 2022. The interview further revealed that Resident 36 was told that return to Personal Care could not occur until the facility re-opened due to the virus. Resident 36's last covered day for Medicare was January 1, 2022. Interview with Resident 36 further revealed that Resident 36 never had the GI virus and all meals had to be consumed in resident rooms because no one was allowed to go to the dining room. Interview with Employee E3 on January 20, 2022 at 1:00 p.m. revealed Resident 36 was to have a home visit with therapy to Personal Care. The scheduled home visit did not occur between January 1, 2022 and January 20, 2022 due to concern for possible GI virus transmission. The interview further revealed that no employee or resident was permitted to enter and exit personal care community from December 28, 2021 until the time of the interview, therefore a home visit and discharge could not occur for Resident 36. Observation of signage at facility entrance on January 20, 2022 revealed that the facility was open to visitation as of January 20, 2022. Further review of the Line Listing report revealed that the last date that a resident had symptoms was January 12, 2022. The facility had been closed from December 28, 2021 to January 20, 2022 to visitation. The above information was conveyed to the Nursing Home Administrator on January 21, 2022 at approximately 1:00 p.m. 28 Pa. Code 201.29(a) Resident Rights

Based upon review of facility policy and procedure, observation and interview it was determined that the facility did not use transmission based precautions to protect residents from a virus that caused a facility-wide visitation closure for approximately one month. Findings include: Review of facility policy and procedure titled Infection Prevention and Control Program, revised June 4, 2021 revealed transmission-based precautions will be utilized, in addition to Standard Precautions, when the route of transmission is not completed interrupted using Standard Precautions alone. Observation of signage at the facility entrance on January 18, 2022 at 9:30 a.m. revealed that the facility was denying visitation to residents due to a GI (gastrointestinal) virus. The signage further revealed that review of the visitation closing would be held on January 18, 2022. Observation of signage at the facility entrance on January 18, 2022 at 2:30 p.m. revealed that the closing of visitation would continue until January 20, 2022 at which time another review would be held. Observation of meals on January 18, January 19 and January 20, 2022 revealed all residents ate meals in their rooms with no residents being permitted to eat in any of the dining rooms in the facility. Interview with the Nursing Home Administrator during Entrance Conference on January 18, 2022 at 10:00 a.m. revealed that the facility had stopped visitation to residents on December 28, 2021 due to an unidentified GI virus. Review of a laboratory test result dated January 11, 2022 revealed Resident 17 tested positive for norovirus (GI virus). The sample was obtained January 11, 2022 and resulted January 18, 2022. Observation of all nursing units in the facility failed to reveal evidence that transmission-based precautions were in use. Interview with Employee E4 on January 21, 2022 at 12:30 p.m. regarding Resident 17's care plan revealed that during the course of the GI outbreak only standard precautions were used. The interview further revealed that no transmission-based precautions (i.e. contact precautions) were used during the outbreak that caused the facility to undergo visitor and dining restrictions. The above information was conveyed to the Nursing Home Administrator on January 21, 2022 at approximately 1:00 p.m. The facility failed to use transmission-based precautions during a GI virus outbreak which resulted in a facility shut-down to visitation and dining services. 28 Pa. Code 201.18(b)(1) Management