**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 25 residents reviewed (Residents 2 and 3).Findings Include: Review of Resident 2's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition where the kidneys gradually lose their ability to filter waste products from the blood) and anxiety disorder (excessive fear and worry that are difficult to control and interfere with daily life).Review of Resident 2's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated June 5, 2025, revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (C. Number of falls since admission or Prior assessment - Major injury) was marked one, indicating Resident 2 had a fall with major injury during the look back period.Review of Resident 2's clinical record revealed they had a fall on May 31, 2025, that resulted with no injuries, and a fall on May 12, 2025, that resulted with a minor injury. Review of Resident 3's clinical record revealed diagnoses that included CKD and anxiety disorder.Review of Resident 3's Quarterly MDS dated [DATE], revealed section N0415. High-risk drug classes: use and indication (C. Antidepressant) is marked Yes, indicating Resident 3 was administered an antidepressant medication during the look back period. Review of Resident 3's current physician orders revealed Resident 3 was not currently receiving any antidepressant medications. Further review of Resident 3's discontinued medications revealed that Resident 3 was prescribed Sertraline 50 milligrams by mouth daily for major depressive disorder, however, that was discontinued on May 3, 2023.During an interview with the Nursing Home Administrator on August 28, 2025, at approximately 1:00 PM, it was revealed that Resident 2's fall MDS was marked in error, and was corrected, as well as Resident 3's antidepressant MDS was marked in error and was corrected; and that she would have expected them to have been completed accurately. 28 Pa. Code 211.5(f) Clinical records.28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on observation, policy review, staff interviews, and review of glucometer manufacturer's guidelines, it was determined that the facility failed to provide a safe and sanitary environment that supports infection prevention and control regarding use of glucose meter (a medical device for determining the approximate concentration of glucose in the blood) disinfection for one of five nursing units. Findings include: A review of the facility policy, titled Obtaining Blood Glucose Level and Disinfecting Glucometer, last reviewed January 28, 2025, stated, use of one of the following manufacturer-approved EPA (Environmental Protection Agency)-registered disinfectant wipes or a 70% isopropyl alcohol swab to wipe down the entire surface of the glucometer. A review of the manufacturer's guidelines for the facility's brand of glucometer stated, Cleaning can be accomplished by wiping the meter down with soap and water or isopropyl alcohol but will not disinfect a meter. The manufacturer's guidelines referenced Centers for Disease Control as their resource for blood glucose monitoring safety. During an interview with Employee 1 (Registered Nurse) the Employee was asked to review her process after using the glucometer on a resident. Employee 1 stated the following, after leaving the residents room and while walking down the hall, I wipe the glucometer down with alcohol wipes. Employee 1 showed the glucometer storage bag filled with alcohol wipes. Employee 1 was asked what she does after cleaning the glucometer with alcohol wipes. Employee 1 responded, I place the glucometer back in the storage bag and in the medication cart. Employee 1 was questioned about the requirement to use a disinfectant, and she stated out loud looking at other staff, we aren't allowed to use just alcohol wipes to clean the glucometer. During an interview with the Nursing Home Administrator on August 27, 2025, at 1:45 PM, she was asked if she expected staff to disinfect the glucometer and she replied, I expect staff to follow the policy. The NHA was asked if she expects staff to follow CDC (Centers for Disease Control) guidelines for disinfection and she replied yes. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and to promote dignity related to use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of one residents reviewed for catheter use (Resident 6). Findings Include: Review of facility policy, titled Foley Catheter Care effective March 1996, revealed, The collection bag should be placed below the resident, but not touching the floor, to allow for proper gravity drainage and prevent backflow of urine up the tubing and into the collection bag. Collection bag covers, also called dignity bags, are available and will be used to promote care for the resident to maintain or enhance their dignity and respect and to prevent the collection bag from dragging on the ground. Review of Resident 6's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and retention of urine. Observation on September 6, 2023, at 1:18 PM, revealed Resident 6 laying in bed with their foley catheter collection bag hanging on the side of the bed; the edge of the bag was touching the floor. Additionally, it was observed that the collection bag and the urine inside was visible from the hallway. During the observation, a visitor was present in the hallway. A later observation on that date, at 1:39 PM, revealed that the collection bag had been emptied, but was still touching the floor, and was still exposed and visible from the hallway. During an interview with Employee 2 (Nurse Aide) on September 6, 2023, at 1:43 PM, she revealed that Resident 6 used to have a dignity cover for their collection bag, but she was not sure where it went. During an interview with the Director of Nursing on September 7, 2023, at 11:08 AM, she revealed that Resident 6's catheter collection bag was replaced with one that had a built-in dignity cover. 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, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two of five nourishment areas. Findings include: Review of facility policy, titled 5.2 Food Storage- Sanitation and Infection Control last revised March 2020, revealed, All products are labeled and dated with a receiving date .discard outdated stock. Review of facility policy, titled Storage of Refrigerated and Frozen Foods last revised March 2020, revealed butter has a maximum refrigeration period of up to three months, and open fruit juice cartons have a maximum refrigeration period of up to seven days. Observation of the dry storage area on September 5, 2023, at 9:50 AM, revealed two bags of red skin potatoes not dated. Observation in walk-in freezer unit on September 5, 2023, at 9:57 AM, revealed a pan of frozen prepared food labeled Denver ham, with a use by date of August 26, 2023; a bag of pureed strawberries with a use by date of August 13, 2023; and a bag of hot dog buns not labeled or dated. Interview with Employee 1 (Food Service Director) on September 5, 2023, at 9:58 AM, revealed he would expect items to be labeled and dated per facility policy, and discarded after use by dates. Observation of the walk-in refrigerator on September 5, 2023, at 9:59 AM, revealed one box of tomatoes that were rotten. Observation of the three-compartment sink in the main kitchen area on September 5, 2023, at 10:03 AM, revealed the sanitizing sink was full of water and pans. The surveyor requested Employee 1 to test the concentration (unit of measure) of the sanitizer water with the strips provided; after Employee 1 tested the sanitizer water, observation of the testing strips revealed they had an expiration date of August 1, 2021. Observation during initial tour of the [NAME]/Hampden pantry area refrigerator on September 5, 2023, at 10:10 AM, revealed: eight grape juices without a date; one bag of individual margarine packets without a date; one container of salad labeled use by 9/4; and one container of prune labeled use by 9/3. Further observation of the [NAME]/Hampden pantry area freezer on September 5, 2023, at 10:13 AM, revealed a container of frozen hot dogs labeled use by 8/8. Observation during initial tour of the of the [NAME] pantry area on September 5, 2023, at 10:19 AM, revealed a container of individual whipped butter packets on the counter with a label 9-1-23 to 3-1-24, and a container of brown sugar in the cabinet without a label or date with a spoon stored inside. Further observation during initial tour of the of the [NAME] pantry area refrigerator on September 5, 2023, at 10:23 AM, revealed an open container of thickened apple juice with an open date of August 9, 2023; one container of thickened lemon water without an open date; one pan of cinnamon Danish without a label or date; half of an open pan of jelly Danish without a label or date; and one container of lemon pudding without a date. Interview with the Nursing Home Administrator on September 6, 2023, at 2:06 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food and kitchen equipment are stored and utilized and in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on observations, policy review, interviews, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two of 24 records reviewed (Residents 11 and 35). Findings include: Review of Resident 11's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebral infarction (inability to move, severe weakness, or rigid movement on either the right or left side of the body, resulting from area of dead tissue in the brain caused by blockage or narrowing in the arteries supplying blood and oxygen to the brain) and scoliosis (condition characterized by sideways curvature of the spine or back bone). During an interview with Resident 11 on September 27, 2022, at 9:07 AM, she revealed that she was concerned that a couple weeks ago a nurse aide transferred her to the bathroom using a sit-to-stand lift (mechanical device that is used to assist an individual with standing and transferring) without the use of a second person. Review of facility policy titled Lift-Sara, effective October 1994, revealed that, when using the lift, Use two people for resident and staff safety. Review of Resident 11's current care plan revealed that she was to utilize a Sara lift (sit-to-stand lift) with assist of two persons for transfers. This intervention was effective September 16, 2019. During an interview with Employee 1 (Nurse Aide) on September 28, 2022, at 12:48 PM, she confirmed that, on the date in question, she utilized a lift to transfer Resident 11 without a second person being present. She also revealed that she was aware of the need for two persons when using a lift to transfer a Resident. During an interview with the Nursing Home Administrator (NHA) on September 28, 2022, at 11:15 AM, NHA confirmed that the facility was aware of the Resident's concern, and that Employee 1 was counseled immediately following the incident. Review of Resident 35's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults) with behavioral disturbances and weakness. Observation of Resident 35 on September 26, 2022, at approximately 11:05 AM, revealed mild edema (swelling) noted to left foot. Resident was seated in a wheelchair with feet on the floor and tubigrips (a tubular elastic bandage designed to provide tissue support and compression in the treatment of conditions such as edema, soft tissue injuries, and weak joints) noted on bilateral lower extremities. Observations on September 27, 2022, at approximately 9:40 AM, and September 28, 2022, at approximately 12:55 PM, revealed the same aforementioned findings. Review of Resident 35's physician orders revealed an order dated July 15, 2022, for confirm placement of tubigrips to bilateral lower extremities on in the morning and remove at bedtime for edema. Resident 35's progress note revealed a note dated June 7, 2022, at 10:50 PM, that indicated that the Resident had bilateral lower extremity dependent edema; bilateral ankles and feet with purple coloring; Resident placed in bed with feet propped. Another progress note dated June 8, 2022, at 3:17 PM, indicated that the Certified Registered Nurse Practitioner (CRNP) was notified that Resident 35's wife was concerned about the Resident's dependent edema. The note further indicated that the CRNP gave no new orders at that time. A nutrition/dietary note dated July 11, 2022, at 1:14 PM, indicated the Resident had experienced a weight gain, likely due to the existence of bilateral lower extremity edema combined with excellent intakes. A nurse's note dated July 15, 2022, at 11:11 AM, indicated a new order had been obtained to apply tubigrips to bilateral lower extremities daily-apply in AM and remove in PM. A quarterly nutrition/dietary note dated August 2, 2022, at 12:41 PM, indicated the Resident had experienced a significant weight gain over the last month and over the last six months. This note indicated the weight gain was partially fluid related as the Resident has a history of dependent edema in bilateral lower extremities. Review of Resident 35's care plan revealed that the edema concern was not added to the Resident's care plan until August 3, 2022, and at that time it was added under the Resident's nutritional focus, which stated the Resident's weight gain was partially fluid related; Resident with history of dependent edema to bilateral lower extremities. A subsequent entry on the Resident's nutritional care plan, dated September 13, 2022, indicated that the Resident's bilateral lower extremity edema had improved with the compression socks. As of review date of care plan on September 29, 2022, the tubigrips were not included as an intervention on the care plan. During an interview with the NHA on September 29, 2022, at approximately 9:40 AM, the NHA was made aware of the care plan development concern, and NHA indicated she would look into it. Email communication received from the NHA on September 29, 2022, at 12:08 PM, the NHA indicated that she understood the concern that, although the edema was care planned under the Resident's nutritional focus, the intervention for the placement of the tubigrips was not added to the care plan. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services