Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed for limited range of motion (Resident 9). Findings include: Review of facility policy, titled Restorative Nursing Program (RNP), last revised June 2024, read, in part, Restorative care is promoted to enable residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. A licensed nurse shall be appointed as the Restorative Nurse to oversee, coordinate and monitor the RNP. A Certified Nursing Aid will be appointed as the Restorative Aide to implement programs put in place by the restorative nurse. The Restorative Aide will complete task documentation as indicated by program requirements. Review of Resident 9's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side (a condition where a stroke has caused paralysis or weakness on one side of the body), and pain in left ankle. Review of Resident 9's care plan revealed a focus area I have limited physical mobility related to weakness, hemiplegic affecting left side, initiated on February 21, 2024, with interventions for three restorative nursing programs, initiated on February 21, 2024. Further review of Resident 9's care plan revealed a focus area that read, in part, I have an activities of daily living self-care performance deficit related to dementia, history of falling, muscle weakness, initiated on January 10, 2024, with interventions for two nursing restorative programs, initiated on February 21, 2024 Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Active Range of Motion Program #1 Standing at hall rail with gait belt remind to straighten posture every day shift 7-3. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 4, 10, 12, 21, 23, and 24, 2024; April 1, 7, 12, 20, 21, 24, and 28, 2024; May 2, 4, 16, 22 and 27, 2024; June 15 and 16, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 7 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Active Range of Motion Program Using 2# free weight, do right shoulder press, chest press, bicep curls, forearm pro/supination, wrist flex/extension. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 4, 10, 12, 23, and 31, 2024; April 7, 12, 20, and 28, 2024; May 2, 4, 16, and 27, 2024; June 2 and 16, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Dressing/Grooming Program #1 Give washcloth in right hand to wash face, chest and left hand. Cue to lift right arm for sleeve of clothing. Cue to lift right leg for pant leg, sock and shoe. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on March 16, 2024, and April 12, 2024. The task documentation was left completely blank on May 26, 2024, and August 12, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Transfer Program #1 provide minimum assist to contact guard assistance for stand pivot transfer to bed, toilet, wheelchair. Transfer to [Resident 9's] right side when able. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 12 and 23, 2024; April 7, 12, and 28, 2024; May 3, 4, 16 and 27, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Walking Program #1 Left lower extremity bracing and gait belt with wheelchair following and cueing for sequencing with quad cane. 50-70' with contact guard assistance/minimum assist. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 10, 12, 23, 24, 30 and 31, 2024; April 6, 7, 10, 12, 14, 20, 21, 27 and 28, 2024; May 2-4, 15, 16, 22, and 27, 2024; June 1,2, 5, 9, 13, 16, 22, 29 and 30, 2024; July 7, 19, and 31, 2024; and August 4, 6, 11, and 24, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Interview with the Director of Nursing on September 5, 2024, at 10:34 AM, revealed he was unable to locate documentation to indicate Resident 9's restorative programs were implemented or that he had refused them on the aforementioned dates. No further information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 14 residents reviewed (Residents 8 and 40). Findings include: Review of facility policy, titled Comprehensive Care Plan, last revised June 10, 2024, read, in part, The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental, emotional, and psychosocial wellbeing. Care Plans will be revised as information about the resident and the resident's condition changes. The Interdisciplinary Team is responsible for the review and updating of the care plans. Review of Resident 8's clinical record revealed diagnoses that included jaw pain, anxiety disorder (a persistent feeling of worry, nervousness, or unease), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 8's care plan revealed an activities care plan that had not been updated since October 21, 2022. Further review of Resident 8's activities care plan revealed an intervention for I prefer to dine in the lounge or dining hall, initiated on October 21, 2022. Observation of Resident 8 on September 3, 2024, at 11:57 AM, revealed she was sitting in her room, eating lunch in her recliner. Observation of Resident 8 on September 4, 2024, at 12:04 PM, revealed she was sitting in her room, eating lunch in her recliner. Interview with Employee 1 (Nurse Aide) on September 5, 2024, at 9:52 AM, revealed Resident 8 has been eating in her room since she came here. Interview with Resident 8 on September 5, 2024, at 9:55 AM, revealed she has been eating in her room since she admitted to the skilled nursing facility from her cottage in 2022, because of her issues with her jaw and she can't wear her dentures. Interview with the Director of Nursing (DON) on September 5, 2024, at 11:54 AM, revealed he would expect Resident 8's care plan to be updated to reflect that she prefers to dine in her room. Review of Resident 40's clinical record revealed diagnoses of post-traumatic stress disorder (PTSD-a mental and behavioral disorder that can develop after a person experiences or witnesses a traumatic event) and generalized anxiety disorder (a mental health condition that causes people to feel excessive, irrational, and uncontrollable worry about everyday things for months or years). Review of Resident 40's electronic medical record revealed the diagnosis of post-traumatic stress disorder was added to her medical diagnoses on October 24, 2023. Review of Resident 40's care plan on September 3, 2024, revealed a care plan with a focus area of, I have a mood problem related to depression, anxiety, vitamin D deficiency and PTSD, with a date initiated of October 12, 2023. No triggers for Resident 40's PTSD were found on the care plan. Interview with the Nursing Home Administrator on September 4, 2024, at 1:20 PM, revealed that Resident 40's PTSD triggers were identified at the time of Resident 40's admission and should have been added to the care plan. 28 Pa. Code 211.10(d)(a) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 13 residents reviewed (Resident 23). Findings Include: Review of Resident 23's clinical record revealed diagnoses that included chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly) and essential hypertension (high blood pressure). Review of Resident 23's admission MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated July 8, 2023, revealed that Section O0100, Special Treatments, Procedures, and Programs (K. Hospice Care, 1. While not a resident of this facility and within the last 14 days) was marked No. Review of a Promedica Revocation of Hospice Benefit document dated October 10, 2023, revealed that Resident 23 started hospice care on April 3, 2023, and revoked hospice on October 10, 2023. Written communication received from Employee 3 (Registered Nurse Assessment Coordinator) on November 1, 2023, revealed that Section O was marked in error and has since been amended to reflect Resident 23 was receiving hospice services prior to coming into the facility. Interview with the Nursing Home Administrator and Director of Nursing on November 2, 2023, at 12:05 PM, revealed that they would have expected Section O. K. Hospice care to have been captured on the MDS completed on July 8, 2023. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, clinical 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 of one of 13 residents reviewed (Resident 45). Findings include: Review of facility policy, titled Continuous Positive Airway Pressure [CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing] disinfecting, effective June 24, 2019, revised October 1, 2023, read, in part, orders to clean and sanitize CPAP machines will be placed into the resident's treatment administration record. Review of Resident 45's clinical record documented they were admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), asthma (a condition in which a person's airway becomes inflamed, narrow, and swells, and produce extra mucus, which makes it difficult to breathe), anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). Additionally, on November 2, 2023, the diagnosis of obstructive sleep apnea (intermittent airflow blockage during sleep) was added. Observation on October 31, 2023, at 9:25 AM, in Resident 45's room revealed, on the top of the dresser to the right of the recliner, was a CPAP machine, and the mask was uncovered and resting on the floor. During an interview with Resident 45 on October 31, 2023, at 9:29 AM, it was revealed that she utilizes a CPAP machine and is able to manage use of and care of the machine herself. It was revealed that she brought 2 gallons of water from home and also fills the humidifier herself. Continued discussion revealed that the tubing hasn't been changed, the mask hasn't been cleaned, and that she didn't have a bag to store the mask in between use. Observation with Employee 1 (Licensed Practical Nurse) on October 31, 2023, at 1:23 PM, in Resident 45's room revealed the CPAP mask was on the floor in front of her dresser, to the right of her recliner. During an interview with Employee 1 on October 31, 2023, at 1:24 PM, it was revealed that the CPAP mask should be in a plastic bag. It was further reveled that Employee 1 would obtain a bag and let Resident 45 know how to properly store the mask in the bag. Review of Resident 45's September 2023 and October 2023 physician orders and treatment administration records failed to document orders for use of a CPAP machine or cleaning of the CPAP machine. Review of hospital emergency after visit summary dated September 26, 2023, read, in part, to continue use of ResMed with Modem CPAP 10 cm (unit of measure) water, mask, supplies, heated humidifier, compliance data, and small dream [NAME] nasal mask. Review of progress note dated September 27, 2023, (a Wednesday) at 1:40 PM read, in part, Resident post ER for dizziness and headache. No complaint of headache at this time. Resident said she feels dizzy occasionally throughout the shift. And that the oxygen that she wears at night helps a lot. Resident is to receive her CPAP machine Friday per resident. Review of Cardiology consult dated September 22, 2023, documented to continue durable medical equipment -ResMed with Modem CPAP 10cm water, mask, supplies heated humidifier, compliance data, and small dream [NAME] nasal mask, LON99. During an interview with the Nursing Home administrator and Employee 2 (Registered Nurse) Infection Preventionist on November 1, 2023, at 9:40 AM, it was revealed that Resident 45 was admitted to the facility from another skilled Nursing Care facility, and the discharge summary didn't include use of a CPAP machine. It was further revealed that Resident 45's family brought her personal belongings from her home, and the facility didn't realize that Resident 45 had a CPAP machine. It was also revealed that the staff missed the CPAP on the hospital summary and the cardiology consult. Further, it was revealed an order for use of the CPAP should've been obtained and the Resident provided with supplies and educated on the care and storage of the machine and mask. 28 Pa code 211.12(d)(1)(2)-Nursing Services

Based on observation, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to be treated with respect, dignity, and care in a manner that promotes maintenance or enhancement of his or her quality of life for one of 13 residents reviewed (Resident 46). Findings Include: Review of the facility's policy, titled Quality of Life and Dignity for Resident, recently reviewed October 1, 2022, reads, in part, The resident has the right to a dignified existence. Also, A facility must treat each resident with respect and dignity and care .in a manner and environment that promotes maintenance or enhancement of his or her quality of lie. Review of Resident 46's clinical record revealed diagnoses that included retention of urine (a condition in which you are unable to empty all the urine from your bladder) and hypertension (elevated blood pressure). Continued review of Resident 46's clinical record revealed the need for the use of an indwelling foley catheter ( a common type of indwelling catheter. It has soft, plastic or rubber tube that is inserted into the bladder to drain the urine). An observation of Resident 46, on November 13, 2022, at 9:37 AM, revealed the catheter bag to be uncovered with observed urine in the catheter bag. The catheter bag was found to not be covered to ensure privacy and dignity. An inteview with the Director of Nursing, on November 15, 2022, at 11:22 AM, revealed that the catheter bag cover was sent to the laundry for cleaning and not available for use to cover the catheter bag at the time of the observation. 28 Pa. Code 201.29 (j) Resident Rights

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure accuracy of the resident assessment for one of 13 residents reviewed (Resident 29). Findings include: Review of Resident 29's clinical record on November 13, 2022, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (disease in decreases the body's ability 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 29's quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), with an assessment reference date of September 21, 2022, revealed in section N0300 Injections, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days, was coded as 0 indicating Resident 29 had received no injections during the 7 days prior to September 21, 2022. Further, due to assessment response in Section 0300 Injections, Sections N0350 Insulin, subsection A, Insulin injections - Record the number of days that insulin injections were received ., and subsection B, Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days . were subsequently disabled, indicating that the Resident did not receive any insulin injections during the prior 7 days leading up to September 21, 2022. Review of Resident 29's physician orders and Medication Administration Record for the month of September, 2022, revealed that during the 7 day assessment period leading up to the September 21, 2022, assessment date, Resident 29 received insulin injections on 7 of 7 days. During a staff interview on November 14, 2022, at approximately 1:00 PM, the facility was informed of the identified discrepancy with Resident 29's quarterly MDS with an assessment reference date of September 21, 2022. During a staff interview on November 15, 2022, at approximately 11:00 AM, Director of Nursing confirmed that Resident 29's aforementioned MDS was incorrect and that the facility had reviewed the MDS and submitted a corrected assessment. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility documentation, policy review, and staff interviews, it was determined that the facility failed to ensure multi-use medications were dated upon opening for one of two medication storage carts reviewed (second floor medication cart one of two). Findings include: Review of facility policy titled, Med[ication] Pass Policy, initial date March 1, 2012, last reviewed date October 24, 2022, revealed section 1. Documentation, stated, White dots that are on eye drops, ear drops, liquids, injectables, are there so that the nurse who first opens/uses the medication has a place to document his/her initials and the date and time. Unit dose boxes should have the nurse's initials and date and time that the box was opened. The Medication Administration Record (MAR) needs to be marked when a new box, bottle, inhaler, etc. is started. Place a mark with a colored marker on the day/time space when the container has been opened- this is for accountability purposes. PRN [as-needed] medications must have documentation on the front and back of the MAR. You must indicate initials, date, time, and reason for use and effectiveness. Review of the facility's clinical records, including the Medication Administration Record system, revealed that, at the time of the survey, the facility utilized an electronic Medication Administration Record and that the policy indicated a process to document using a Medication Administration Record that was hard-copy (physical sheets of paper utilized to document medication administration and/or nurses notes). During medication administration observations on November 14, 2022, at approximately 10:20 AM, Facility Employee 3 was observed preparing medications to be administered to Resident 45. During the observation, Facility Employee 3 retrieved polyvinyl alcohol 1.4% eye drops for administration. Observations of the polyvinyl alcohol 1.4% eye dropper revealed that it was previously opened. Observations revealed no open date was recorded on the pharmacy bag that contained the eye drops, nor on the container of eye drops. Observations of medication cart one of two for the second floor unit on November 15, 2022, at approximately 1:00 PM, revealed two insulin injector pens that were opened and partially used. Both insulin injector pens had stickers placed by pharmacy for the purpose of recording the date opened, the expiration date of the medication, and the nurses' initials upon opening. Neither insulin pens observed had open dates, nor nurses' initials recorded on the sticker. Observations of Resident 45's polyvinyl alcohol 1.4% drops were also made and revealed that there was still no open date listed on the eye drop or the pharmacy bag that contained the eye drops. At the time of the observation, Facility Employee 3 confirmed that there was no open date on the eye drops; at which time Facility Employee 3 utilized the electronic health record to identify when the eye drops were delivered to the facility. Facility Employee 3 then recorded that date on eye drop container. During a staff interview on November 15, 2022, at approximately 1:15 PM, Director of Nursing (DON) observed the two identified insulin pens and confirmed the absence of a date to identify when the pens were initially opened for use. During the interview, DON revealed that the insulin pens should have had a date that they were opened along with the initials of the nurse that opened them included on the sticker identified for such purpose. During a staff interview on November 16, 2022, at approximately 10:30 AM, the DON was made aware of the observations of Resident 45's eye drops that did not have an open date during medication administration and subsequent observations. During the staff interview, DON revealed that the facility was preparing to increase medication cart checks that are performed by the consulting pharmacist. 28 Pa code 211.9(h) Pharmacy services 28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on observation, product manufacturer label, and facility policy review, it was determined that the facility failed to ensure a medication rate of less than 5 percent. Findings include: Based on observation of 34 medication opportunities, three medication errors were identified, which equated to an error rate of 8.82 percent. Review of facility policy titled, Med[ication] Pass Policy, last reviewed October 24, 2022, revealed that section 3. Medication Administration stated, Inhalers - wait one minute between puffs . During medication administration observations on November 14, 2022, at approximately 10:20 AM, Facility Employee 3 was observed preparing medications to be administered to Resident 45. During the observation, Facility Employee 3 retrieved polyvinyl alcohol 1.4% eye drops for administration. Observations of the polyvinyl alcohol 1.4% eye dropper revealed that it was previously opened. Observations revealed no open date was recorded on the pharmacy bag that contained the eye drops, nor on the container of eye drops. Facility Employee 3 was observed administering the eye drops to Resident 45 at approximately 10:23 AM. During medication administration observations on November 15, 2022, at approximately 9:30 AM, Facility Employee 4 was observed preparing medication to be administered to Resident 8. During preparation, Facility Employee 4 was observed preparing Breo 100 mcg/25 mcg (combination inhalation medication used to treat respiratory disease). Facility Employee 4 also prepared Combivent 20 mcg/100 mcg (combination inhalation medication used to treat respiratory disease). Finally, Facility Employee 4 was observed preparing one packet Metamucil in water for administration to Resident 8. Review of the manufacturer's box for the Breo medication was a sticker with the instructions to allow one full minute after administration of the Breo before administering further inhalation medication. Observation revealed that Facility Employee 4 administered Resident 8's Breo inhalation medication first and then Combivent inhalation medication, with approximately 10 second between each medication and did not allow for a full minute between administrations. Further observation of the medication administration reveled that Resident 8 did not finish the full amount of Metamucil. Facility Employee 4 left the remaining amount of Metamucil on Resident 8's bedside table and left the room and did not observe the complete consumption of the Metamucil. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, and adult protective services, in a form and manner accessible and understandable to residents / resident representatives for two of two resident areas observed (First and Second Floors). Findings Include: Observations on the facility's first and second floors, on November 15, 2022, at 11:32 AM, revealed postings on behalf of residents did not include the required State agencies and advocacy groups elements, including mailing and email addresses. An interview with the Nursing Home Administrator, on November 16, 2022, at 10:38 AM, revealed the facility has created documents for posting with the required information that will presently be available for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on document review and staff interview, it was determined that the facility failed to ensure each resident is informed periodically during the resident's stay of services available in the facility and charges for those services, including any charges for services not covered under Medicare/Medicaid, for two of three residents reviewed at the end of their Medicare A stay (Residents 13 and 32). Findings Include: Review of Resident 13's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form (SNF-ABN) revealed the Resident was discharged from Medicare A skilled services on August 20, 2022. According to the SNF-ABN, Resident 13 would be responsible for the facility's rate of charges not covered under Medicare or Medicaid. Further review of the SNF-ABN reveled Resident 13, nor the Resident's Responsible Party were informed of the charges no longer covered. Review of Resident 32's SNF-ABN revealed the Resident was discharged from Medicare A skilled services on May 17, 2022. According the the SNF-ABN, Resident 32 would be responsible for the facility's rate of charges not covered under Medicare or Medicaid. Further review of the SNF-ABN revealed Resident 32, nor the Resident's Responsible Party were informed of the charges no longer covered. An interview with Employee 2 on November 14, 2022, at 11:37 AM, revealed she historically has not documented or discussed the facility's daily rate of non-covered services, post Medicare A coverage, with the Residents and/or their responsible parties. The interview also revealed the charges would be discussed going forward. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations and staff interview, it was determined that the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances, orally or in writing; the right to file grievances anonymously; the contact information of the grievance official, with whom a grievance can be filed, including his or her name, business address (mailing and email), and business phone number, for two of two resident areas reviewed (First and Second floors) and review of the facility's admission packet. Findings Include: Observations on the first and second floors, on November 14, 2022, at 9:48 AM, and November 15, 2022, at 10:52 AM, revealed no information posted regarding the facility's designated greivance official or the required information, to include the name and contact information. Review of the facility's admission packet revealed no documentation of the designation of a grievance official or the required information, to include the name and contact information. An interview with the Nursing Home Administrator, on November 16, 2022, at 10:43 AM, revealed she and the Director of Social Services handle grievances for the facility. No information regarding an established grievance official or his or her contact information was provided at the time of the survey. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure the development and implementation of a comprehensive plan of care for one of 13 residents reviewed (Resident 20). Findings include: Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of Resident 20's comprehensive plan of care revealed that enabler bars were not included in the comprehensive plan of care. On November 16, 2022, at 9:30 AM, a facility document was reviewed regarding the application of bilateral enabler bars to Resident 20's bed. Review of the document revealed that on August 19, 2022, facility therapy department evaluated Resident 20 due to a decline in ability to perform activities of daily living. The document stated that as a result of the assessment, Therapy determined that the resident needed bilateral enabler bars, Therapy asked maintenance to place enabler bars on the resident's bed, Maintenance placed enabler bars on resident bed as requested. Enabler bars were placed on bed the week of August 22nd [2022] through August 26th 2022. Review of Resident 20's documented Care Conference (multidisciplinary team meeting to discuss changes to a resident's plan of care with the resident and/or resident representative), revealed that Resident 20 had a Care Conference held on September 16, 2022 (prior Care Conference conducted July 29, 2022), due to Resident 20 having a significant change in condition. Review of Care Conference documentation, specifically the Nursing and Rehabilitation/Therapy services sections, revealed that the addition of bilateral enabler bars was not addressed by any discipline in attendance. Specifically, Rehab Summary, stated, Resident requires max encouragement to participate in skilled [physical therapy] treatment sessions to increase [bilateral lower extremity] strength, ambulation and safe transfers. Finally, review of Resident 20's clinical record revealed no documented evidence that the risks and benefits of bilateral enabler bars was discussed and informed consent was obtained for their use for Resident 20. On November 15, 2022, the facility submitted documentation to the State Survey agency that demonstrated the addition of bilateral enabler bars to Resident 20's comprehensive plan of care, which were added on November 14, 2022. 28 Pa code 211.11(a)(d) Resident care plan

Based on policy review, observation, record review, and interviews, the facility failed to complete a risk benefit analysis and obtain consent for use of an enabler bar for three of three residents reviewed (Residents 18, 20, and 46). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body). Interview with Resident 18 on November 13, 2022, at approximately 12:02 PM, it was revealed that she utilized the enabler bars on both sides of the bed to assist her to stand and transfer in and out of bed, and for bed mobility. Further review of Resident 18's clinical record revealed an order for bilateral enabler bars, with an order date of November 14, 2022. Review of progress notes revealed a health status note dated November 14, 2022, at 2:26 PM, documenting order received for bilateral enabler bars, and a message was left for the Resident Representative to return the Director of Nursing's call. Review of Health status note dated November 15, 2022, at 8:05 AM, documented that verbal consent was received from Resident Representative approving Resident 18 to utilize enabler bars. Review of Resident 18's initial enabler bar screenings was dated December 30, 2016, and enablers were indicated for use. Surveyor requested a copy of the consent for use of enabler bars for Resident 18, and was provided a signature page dated December 30, 2016, verifying that the pamphlet Working Together for Safety (education regarding the hazards of side rail usage) was provided to the Resident and/or Resident Representative. Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of Resident 20's clinical record on November 13, 2022, at approximately 3:00 PM, revealed that Resident 20's most recent enabler bar assessment (assessment tool utilized to determine if a resident is a candidate for the safe use of enabler bars) was completed on October 11, 2017. Review of Resident 20's clinical record revealed no assessment for enabler bar since. Review of Resident 20's physician orders revealed no physician order for the bilateral enabler bars. Review of Resident 20's comprehensive plan of care revealed that enabler bars were not included in the comprehensive plan of care. On November 16, 2022, at 9:30 AM, a facility document was reviewed regarding the application of bilateral enabler bars to Resident 20's bed. Review of the document revealed that on August 19, 2022, facility therapy department evaluated Resident 20 due to a decline in ability to perform activities of daily living. The document stated that as a result of the assessment, Therapy determined that the resident needed bilateral enabler bars, Therapy asked maintenance to place enabler bars on the resident's bed, Maintenance placed enabler bars on resident bed as requested. Enabler bars were placed on bed the week of August 22nd [2022] through August 26th 2022. Review of Resident interdisciplinary progress notes for the time period of August 10, 2022, to August 26, 2022, revealed no facility staff member documented the installation of bed enablers to Resident 20's bed frame. Review of Resident 20's documented Care Conference (multidisciplinary team meeting to discuss changes to a resident's plan of care with the resident and/or resident representative), revealed that Resident 20 had a Care Conference held on September 16, 2022 (prior Care Conference conducted July 29, 2022), due to Resident 20 having a significant change in condition. Review of Care Conference documentation, specifically the Nursing and Rehabilitation/Therapy services sections, revealed that the addition of bilateral enabler bars was not addressed by any discipline in attendance. Specifically, Rehab Summary, stated, Resident requires max encouragement to participate in skilled [physical therapy] treatment sessions to increase [bilateral lower extremity] strength, ambulation and safe transfers. Review of Resident 20's clinical record revealed no documented evidence that the risks and benefits of bilateral enabler bars was discussed and informed consent was obtained for their use for Resident 20. During staff interviews on November 14, 2022, the facility Nursing Home Administrator (NHA) and Director of Nursing (DON) was informed of the observations of bilateral enabler bars on Resident 20's bed, the lack of a physician's order for the bilateral enabler bars, the lack of inclusion of bilateral enabler bars in Resident 20's comprehensive plan of care, and the lack of an assessment dated after October 11, 2017, for the use of enabler bars. On November 15, 2022, the facility submitted documentation to the State Survey agency which included a physician's order, dated November 14, 2022 for Resident 20's bilateral enabler bars; an assessment for the safe use of the enabler bars, dated November 14, 2022; and the addition of bilateral enabler bars to Resident 20's comprehensive plan of care, dated November 14, 2022. Review of Resident 46's clinical record revealed diagnoses that included muscle weakness and hypertension (elevated blood pressure). An observation of Resident 46, on November 13, 2022, at 9:35 AM, revealed bilateral enabler bars attached to the bed. Continued review of Resident 46's clinical record revealed a document titled Enabler Bar Screener dated September 27, 2022. The form documents the enabler bars are indicated for use at that time. Further review of Resident 46's clinical record revealed the facility obtained an order for the use of the bilateral enabler bars on November 15, 2022. An interview with the DON on November 15, 2022, at 9:38 AM, revealed the Resident/Responsible Party are notified of the risks and benefits at the time of admission. Review of Resident 46's clinical record revealed no documentation of a review of the risks/benefits of enabler bar use at the time of the screening and indication for use. Interview with the NHA on November 15, 2022, at approximately 9:00 AM, it was revealed that the facility provides the residents and/or resident representatives information about the risks and benefits of utilizing enabler bars at the time of admision, and a consent is signed at that time. 28 Pa. Code 205.71

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and interviews, it was determined that the facility failed to conduct regular inspections of bed rails/enabler bars to identify areas of possible entrapment for three of three residents reviewed (Residents 18, 20, and 46). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record documented diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body). Interview with Resident 18 on November 13, 2022, at approximately 12:02 PM, it was revealed that she utilized the enabler bars on both sides of the bed to assist her to stand and transfer in and out of bed, and for bed mobility. Further review of Resident 18's clinical record revealed an order for bilateral enabler bars, with an order date of November 14, 2022. Review of progress notes revealed a health status note dated November 14, 2022, at 2:26 PM, documenting order received for bilateral enabler bars, and a message was left for the Resident Representative to return the Director of Nursing's call. Review of health status note dated November 15, 2022 at 8:05 AM, documented that verbal consent was received from Resident Representative approving Resident 18 to utilize enabler bars. Review of Resident 18's initial enabler bar screenings was dated December 30, 2016, and enablers were indicated for use. Review of Resident 18's care plan and [NAME] documented use of enabler bars to assist with bed mobility. Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of available information provided by the facility and contained in Resident 20's clinical record revealed no documented measurements of entrapment zones as a result of the use of bed enablers. Review of Resident 46's clinical record revealed diagnoses that included muscle weakness and hypertension (elevated blood pressure). An observation of Resident 46, on November 13, 2022, at 9:35 AM, revealed bilateral enabler bars attached to the bed. Continued review of Resident 46's clinical record revealed a document titled Enabler Bar Screener dated September 27, 2022. The form documents the enabler bars are indicated for use at that time. Further review of Resident 46's clinical record revealed the facility obtained an order for the use of the bilateral enabler bars on November 15, 2022. Interview with the Nursing Home administrator (NHA) on November 15, 2022, at approximately 9:00 AM, it was revealed that the facility does not utilize side rails, they utilize only enabler bars. The facility utilizes only certain style enabler bars, small enough to not cause concerns with entrapment. It was also revealed that the facility does not conduct routine or initial safety measurements. NHA was not aware that measurements of the enabler bars, in relation to the 5 zones of entrapment, was required for enabler bars. It was also revealed that approximately 36 residents utilize enabler bars. It was also noted that, if a resident transfers to another room, the bed moves with them. However, enabler bars are removed from bed frames when they are not utilized or appropriate, and are attached to bed frames as needed. 28 Pa. Code 205.71 Bed and furnishings