**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 24 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], and had diagnoses that included malnutrition, colitis (inflammation of the colon), and dysphagia (difficulty swallowing). The Minimum Data Set Care Area Assessment summary dated November 18, 2024, noted that the resident's dehydration and fluid maintenance and dental care were to be addressed in the care plan. There was no evidence that interventions to address Resident's 10's dehydration and fluid maintenance or dental care included in the current care plan. In an interview on December 5, 2024, at 11:32 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, staff interview, and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Labeling and Dating, dated October 29, 2024, revealed that leftovers were to be labelled with the date that they were prepared and the use-by date. Prepared foods were to be discarded after seven days. Review of the facility's policy entitled, Staff Attire, dated October 29, 2024, revealed that all staff with facial hair were to have it properly restrained. Observations during the tour of the dietary department on December 3, 2024, at 10:12 a.m., revealed the following: In dry storage, there was food and paper debris on the floor under two sets of shelves storing food items. There was flour on the floor below the bulk container of flour. There were two bulk containers of cereal that had food debris and/or a dried liquid ring on the lids. In reach-in freezer #7, there was an accumulation of a frozen liquid on the bottom of the freezer. In reach-in freezer #6, there was an opened, uncovered box of green beans. There was a layer of food debris along the inside bottom of the freezer. In reach-in cooler #5, there was dried white liquid on the floor under the milk storage. In reach-in cooler #4, there were two opened containers with yogurt that had dripped onto the containers and the shelf below. In reach-in coolers #3 and #5, there was a layer of food debris along the bottom of the inside of the coolers. In reach-in cooler #2, there was an opened bag of shredded carrots that was not dated. There was a large bowl coleslaw labeled use-by November 30 and an opened container of bulk applesauce that was dated November 22, 2024. There was a container with leftover pancakes stored directly on top of bread that was not dated. There was a layer of food debris on the bottom of the cooler. In reach-in cooler #1, there was a large container of cooked green beans that was not dated. There were two containers and one metal lid on the floor under a storage rack of pans and containers. Inside the microwave, there were multiple areas of dried food debris. In an interview on December 3, 2024, at 11:10 a.m., the District Manager of the dietary department (DM 1) confirmed the previously mentioned foods should have been dated and expired items removed. Observation during of the lunch meal service tray line on December 4, 2024, from 12:25 p.m. to 12:43 p.m., revealed Dietary Employee 1 (DE 1) and Dietary Employee 2 (DE 2) were both observed to have facial hair of a full beard and mustache that were not covered. In an interview on December 4, 2024, at 12:50 p.m., the DM 1 confirmed that DE 1 and DE 2 should have been wearing beard guards during meal tray line. 28 Pa. Code 201.14(a) Responsibility of licensee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 24 sampled residents. (Resident 63) Findings include: Clinical record review revealed that Resident 63 had diagnoses that included cerebral infarction (stroke) and left-sided hemiplegia (paralysis of one side of the body). The Minimum Data Set assessment dated [DATE], indicated that the resident had no memory impairment and required staff assistance for activities of daily living including bed mobility, transfers, and toileting. Review of the current care plan revealed that the resident had a self-care deficit related to her impaired mobility and the intervention was for staff to ensure that the resident had a safe environment with a working, reachable call bell and staff was to reinforce the need to call for assistance. On January 3, 2023, at 11:40 a.m., the resident was observed in bed and stated they did not know where the call bell was. The call bell was observed on the floor on the left side of the bed, out of the resident's reach. On January 5, 2023, at 10:52 a.m., the resident was observed in bed. The call bell was wrapped around and hanging on the outside of the bed rail on the left side of the bed, out of the resident's reach 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure completion of a Minimum Data Set (MDS) assessment for one of 24 sampled residents. (Resident 59) Findings include: Clinical record review revealed that Resident 59 was discharged from the facility to the hospital on October 9, 2022. There was no evidence that a MDS assessment was completed to reflect the discharge status when the resident was discharged from the facility. In an interview on January 6, 2023, at 10:46 a.m., the Director of Nursing confirmed that the MDS assessment had not been completed when the resident was discharged from the facility on October 9, 2022. 28 Pa. Code 211.5(f) Clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and interview, it was determined that the facility failed to provide personal hygiene services for one of three sampled residents who required assistance with activities of daily living. (Resident 71) Findings include: Clinical record review revealed that Resident 71 had diagnoses that included anxiety, muscle weakness, and contracture of the right hand. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for personal hygiene. On January 4, 2023, at 10:58 a.m., Resident 71 was observed in bed, his fingernails were long and discolored. In an interview at that time, the resident stated that staff had not offered to cut his fingernails and he would prefer his nails to be trimmed and kept short. On January 5, 2023, at 10:37 a.m., Resident 71 was observed in bed, his fingernails remained long and discolored. The resident again stated that staff did not offer to cut his fingernails. Review of Resident 71's bathing record revealed that staff provided a bed bath on January 4, 2023. There was no documentation provided that indicated Resident 71 refused nail care. In an interview on January 5, 2023, at 2:19 p.m., the Director of Nursing stated that the resident's nails needed to be trimmed and that nail care should have been provided with bathing or as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 24 sampled residents. (Residents 9, 72) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included orthostatic hypotension (low blood pressure upon standing), dementia with mild psychotic disturbance, and psychosis. A physician's order dated June 26, 2022, directed staff to administer a medication (midodrine hydrochloride) three times a day to treat the resident's hypotension (low blood pressure). Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at it's highest) of 130 mm/hg (millimeters of mercury) or more. A review of the November and December 2022, Medication Administration Records (MARs) revealed that staff administered the medication when the resident's systolic blood pressure was over 130 mm/hg; twice in November and five times in December 2022. A physician's order dated November 29, 2022, directed staff to administer medication (risperidone) at bedtime every other day for anxiety and related psychosis for 14 days. Review of the MAR for November 2022, and December 2022, revealed no evidence that the medication was given on November 29, 2022, and December 1, 3, and 5, 2022. During an interview on January 6, 2023, at 10:46 a.m., the Director of Nursing confirmed that Resident 9 received the midodrine hydrochloride when the resident's systolic blood pressure was above 130 mm/hg and that there was no evidence that risperidone was administered as ordered. Clinical record review revealed that Resident 72 had diagnoses that included hypotension (abnormally low blood pressure). On November 1, 2022, a physician ordered that staff administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure greater than 130 mm/Hg. A review of the November and December 2022, MARs revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter one time in November and four times in December 2022. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and observation, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of 24 sampled residents. (Resident 76) Findings include: Clinical record review revealed that Resident 76 had diagnoses that included diabetes mellitus, muscle weakness and a history of a pressure induced deep tissue injury to the left heel. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was totally dependent on staff for activities of daily living. A physician's order dated May 19, 2022, directed staff to apply heel boots to both feet while the resident was in bed. On January 3, 2023, at 1:27 p.m., and January 4, 2023, at 10:32 a.m., and 11:42 a.m., Resident 76 was observed in bed, the resident was not wearing heel boots. The boots were observed on the resident's bed side stand. There was no documentation provided that indicated Resident 76 refused the heel boots. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services to restore bladder function as much as possible to residents identified with a decline in urinary continence for one of 32 sampled residents. (Resident 24) Findings include: Review of the facility policy entitled, Incontinence, revised January 1, 2023, revealed that based on the resident's comprehensive assessment, all residents who were incontinent would receive appropriate treatment and services to prevent infections and to restore continence to the extent possible. Clinical record review revealed that Resident 24 had diagnoses that included muscle weakness, abnormalities of gait and mobility, and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was occasionally incontinent of bladder and a bowel and bladder evaluation dated May 29, 2022, determined that the resident was continent of bladder. Review of MDS assessments dated August 12 and November 12, 2022, revealed that Resident 24 had a decline in continence and had become frequently incontinent of bladder. Nurse Aide documentation for 30 days prior to January 5, 2023, reflected that the resident continued to experience frequent episodes of urinary incontinence. There was a lack of documentation to support that services were provided to address Resident 24's decline in bladder function. During an interview on January 5, 2023, at 2:25 p.m., the Director of Nursing confirmed that a decline in continence should have been evaluated and resulting interventions implemented. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's meal cart delivery time sheet, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with the resident needs for four of 24 sampled residents. (Resident 30, 54, 76, 83) Findings include: Review of the facility's meal schedule revealed that the scheduled time for lunch on the [NAME] wing nursing unit was 12:05 p.m., and the scheduled time for lunch on the North wing nursing unit was 12:10 p.m. Clinical record review revealed that Resident 30 had diagnoses that included diabetes mellitus and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 4, 2023, at 1:32 p.m., Resident 30 stated that lunch typically arrived late. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 30 received a lunch tray at 1:34 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 54 had diagnoses that included severe protein calorie malnutrition, and dysphagia. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 3, 2023, at 1:13 p.m., Resident 54 stated that lunch had not yet arrived and was over an hour late. Observation of the lunch being served on the [NAME] wing on January 3, 2023, revealed that Resident 54 received a lunch tray at 1:21 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 76 had diagnoses that included diabetes mellitus, muscle weakness, and anxiety. Review of the MDS assessment dated [DATE], revealed that Resident 76 was cognitively impaired and was totally dependent on staff for eating. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 76 received a lunch tray at 1:28 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 83 had diagnoses that included diabetes mellitus, severe protein calorie malnutrition, and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 4, 2023, at 1:18 p.m., Resident 83 stated that lunch had not yet arrived and was over an hour late. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 83 received a lunch tray at 1:26 p.m., over an hour past the scheduled meal time. In an interview on January 5, 2023, at 12:30 p.m., the Administrator stated that lunch was served later than the scheduled time on the North wing nursing unit on January 4, 2023. In an interview on January 6, 2023, at 12:30 p.m., the Administrator stated that lunch was served later than the scheduled time on the [NAME] wing nursing unit on January 3, 2023.