Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58). Findings include: Review of Resident 10's clinical records revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. The resident had an order for IV (Intravenous- a medication administered through a needle or tube inserted into a vein) antibiotics. Observation conducted on March 7, 2024, at 11:00 a.m., revealed a central line catheter to Resident 10's right upper chest. Observation conducted of Resident 10's room on the first three days of the survey failed to reveal evidence of EBP (Enhanced Barrier Precautions) signage or PPE (Personal Protective Equipment). Observation conducted on May 10, 2024, at 11:01 a.m., revealed Resident 21 had a pressure ulcer to the sacrum. Continued observation revealed resident had an indwelling foley catheter (flexible tube inserted into the bladder for removing fluid). An observation of Resident 21's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 50's clinical record revealed diagnosis list includes a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 56's clinical record revealed diagnosis list including but not limited to Gastrostomy Tube. Observation conducted of Resident 56's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 58's clinical records revealed the resident had an indwelling Foley catheter. Observation conducted of Resident 58's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE information regarding the facility's EBP process/procedures. Interview with non-licensed Employees E3 and E4 was conducted on May 10, 2024. Both employees were unable to provide explanation of Enhanced Barrier Precautions and how it relates to residents. An interview with the Director of Nursing on May 10, 2024, at 12:30 p.m., was conducted. The DON reported that the facility had not implemented the Enhanced Barrier Precaution process and was still in the process of educating staff. The above information was presented to the Nursing Home Administrator on May 10, 2024, at 1:45 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care regarding an exit-seeking behavior for one of the 20 residents reviewed (Resident 60). Findings include: Review of Resident 60's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), mild cognitive impairment, and Depression. Review of the nursing progress notes dated April 20, 2023, at 3:21 p.m., revealed Resident 60 was trying to get into the elevator, resident was informed that she/he cannot leave the floor alone, a resident replied I'm getting off this floor one way or another. A monitoring device was placed on the resident's right ankle. Review of Resident 60's elopement assessment completed on April 20, 2023, revealed resident was At Risk for Elopement. Review of Resident 60's current plan of care failed to reveal, the facility had developed an elopement/exit-seeking behavior care plan for the resident. Interview conducted with the Director of Nursing on July 13, 2023, at 10:00 a.m., confirmed an elopement/exit-seeking behavior care plan was not developed for Resident 60. The facility failed to develop a comprehensive elopement/exit-seeking behavior care plan for Resident 60. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/19/22

Based on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to timely address and notify the physician of a significant weight change of two of the 20 residents reviewed (Resident 28 and 51). Findings include: Review of the facility's policy titled Weights, last reviewed on February 8, 2022, revealed all residents are weighed on admission, weekly x four, monthly as a means of monitoring nutrition. Compare the weight to the last recorded weight, if a gain or loss falls within the parameters below, reweight. Parameters for evaluation of the significance of unplanned and undesired weight loss are as follows: 1 month-5% is significant weight loss, greater than 5% is severe loss; 3 months-7.5% is significant weight loss, greater than 7.5% is severe loss; and 6 months-10% is significant weight loss, greater than 10% is severe loss. If the resident falls within the parameters listed above, notify the Dietitian. Interview conducted with the Director of Nursing on July 12, 2023, at 1:00 p.m., revealed nursing is responsible for notifying the physician of a significant weight change in the residents. Review of Resident 28's diagnosis list revealed aftercare following explantation of left knee joint prosthesis, and Sepsis (body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). Review of Resident 28's weights and vitals revealed a weight of 246.8 lbs. on June 24, 2023, and 191 lbs. on June 30, 2023, 55.8 lbs. (22.61%) weight loss in six days. The resident's weight was not checked until July 11, 2023, which had a result of 189.4 lbs. Review of the nursing progress notes dated June 30, 2023, revealed admission weight marked as 264 pounds, the last weight noted in epic (hospital record) was 265 pounds on June 17, 2023. The resident was weighed yesterday via the total lift at 191 pounds. Will continue to monitor. Further review of Resident 28's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician notified. Interview with Employee E7, Dietician was conducted on July 12, 2023, at 12:40 p.m. Employee E7 reported that she/he consulted the resident on July 6, 2023, for an abnormal Albumin level but was not notified of the significant weight loss of the resident. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was not notified of Resident 28's significant weight change. Review of Resident 51's weights and vitals revealed a weight of 252.6 lbs. on June 19, 2023, and 238.1 lbs. on July 3, 2023, a 14.5 lbs. (7.78%) weight loss in two weeks. Further review of Resident 51's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician was notified. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was not notified of Resident 51's significant weight change. The facility failed to ensure Resident 28's and 51's significant weight change was timely addressed, and physician was notified. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/19/22

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to obtain physician orders for dialysis services for one of one resident reviewed (Resident 57). Findings include: Review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE]. 2023, with diagnoses including Renal Failure. Review of Resident 57's care plans revealed, Resident 57 received dialysis every Tuesday, Thursday, and Saturday. Review of Resident 57's clinical record failed to reveal as of July 12, 2023, a physician's order for the resident to receive dialysis services. Interview with the Nursing Home Administrator and Director of Nursing on July 13, 2023, at approximately 2:30 p.m. confirmed, Resident 57 has been receiving dialysis treatments three times each week since hisher admission on [DATE]. 2023, but there was no physician's order for dialysis treatment obtained until July 13, 2023. The facility failed to ensure Resident 57 had a physician order for Dialysis services that resident receives three times a week. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prepare food under sanitary conditions in one of four dining rooms. (5th floor) Findings include: Review of facility policy, Single use gloves and hair restraints, policy revised date May 20, 2019, revealed that beard restraints are to be worn if facial hair growth is more than ½ inch long. This includes goatees as well. Hair restraints (including hair net or a hat). are to be worn during meal service in the pantries, while food is actively being prepared, served or cooked. Observation on July 10, 2023, at 12:15 p.m. during the lunch meal revealed two dietary staff (E4 and E5) bringing plated food from the pantry without beard guards. Observations also included the food was being delivered from the pantry without a lid and placed on trays to be delivered to resident rooms. The tray cart was in the dining room were residents were seated. Observation of the pantry revealed a tray line (where the food is plated) and a room that contained a trash can and dirty plates and trays from the previous meal. Dietary Aide E4 and E5, would take one plate at a time from the tray line, through the room, to the dining room and place it on the tray cart and then a lid would be placed over the food. Observation conducted on fifth floor dining room revealed dietary staff, employee E6, enter dining room then wipe nose using gloved right hand. Employee E6 proceeded to nearest table to assist two residents with meal items. Employee E6 used residents' utensils to cut food items and moved a baked potato using the same glove(s) that were used to wipe nose prior to assisting the residents. Employee E6 was not observed changing gloves or sanitizing hands/gloves between wiping nose and handling residents eating utensils or food. Interview on July 11, 2023 at approximately 11:30 a.m. with Dietary Manager E3, revealed that beard guards must be worn in the pantries. It was also revealed, that food distribution {as explained above) was not to the facilities standards. The facility failed to ensure food was served in sanitary conditions in one of four dining rooms. 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.6(f) Dietary Services