**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure resident privacy for one of four residents reviewed (Resident 3).Findings include: Clinical record review for Resident 3 revealed a quarterly MDS assessment dated [DATE], that assessed Resident 3 as having a memory problem and that he had severe cognitive impairment (never or rarely made decisions). Review of an incident investigation dated September 5, 2025, revealed that Employee 3 (nurse aide) reported to the Director of Nursing that Employee 5 (nurse aide) sent an electronic private message with a picture attachment of Resident 3. Resident 3's face was obscured by a filtering program; however, Employee 3 was able to identify that it was a facility resident. Statements obtained by the facility during the investigation determined that Employee 5 sent the same photo to Employee 4 (nurse aide). The facility substantiated that Employee 5 took and disseminated a photo of Resident 3 who was incapable of giving consent to be photographed. Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and services for an indwelling urinary catheter as ordered by the physician for one of one resident reviewed for urinary catheter concerns (Resident 1).Findings include: Clinical record review for Resident 1 revealed physician orders to maintain a coude foley catheter (flexible tubing inserted into the bladder to drain urine; a coude catheter is equipped with a bent tip to allow passage beyond obstructions such as the prostate gland) for obstructive uropathy (blockage in the urinary system that hinders urine flow; commonly an enlarged prostate) as follows: 24 French (scale where one French unit corresponds to approximately 0.33 millimeters in diameter) coude foley with 10 cc (cubic centimeters, one cc equals one milliliter) balloon changed monthly every 30 days and as needed for blockage or obstruction. This may only be changed by the registered nurse (dated May 31, 2025, to August 29, 2025). 24 French coude foley with 30 cc balloon changed monthly every 30 days and as needed for blockage or obstruction. This may only be changed by the registered nurse (dated August 29, 2025). Review of Resident 1's treatment administration record dated July 2025 revealed that Employee 1 (licensed practical nurse) documented that he changed Resident 1's coude catheter on July 30, 2025 (although Resident 1's physician order stipulated that the registered nurse complete the treatment). Review of Resident 1's treatment administration record dated August 2025 revealed that Employee 6 (registered nurse) changed Resident 1's coude catheter on August 8, 2025. Nursing documentation by Employee 6 dated August 8, 2025, at 10:02 PM indicated that changing Resident 1's coude catheter was effective for blockage/obstruction. Nursing documentation dated August 29, 2025, at 9:59 AM revealed that the Director of Nursing changed Resident 1's catheter for monthly change. Resident 1's clinical record did not contain evidence of a complication (e.g., blockage or obstruction) that warranted changing the indwelling catheter sooner than 30 days from the previous change (that occurred on August 8, 2025). Nursing documentation by Employee 2 (licensed practical nurse) dated April 30, 2025, at 2:03 PM reiterated that a registered nurse changed Resident 1's coude catheter on August 29, 2025. The facility failed to ensure that Resident 1's physician ordered treatment for his indwelling urinary catheter was completed by the appropriate licensed staff at the appropriate schedule. Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail hygiene for one of three residents reviewed for activities of daily living concerns (Resident 46). Findings include: Observation of Resident 46 on July 30, 2025, at 11:47 AM revealed his fingernails were long (extending beyond the tips of his fingers) with darkened material under them. Clinical record review for Resident 46 revealed that the facility developed a plan of care to address Resident 46's risk for alteration in skin integrity related to poor self-care and history of picking at skin (initiated October 4, 2024). A plan of care initiated by the facility on October 4, 2024, noted Resident 46's self-care deficit regarding activities of daily living that listed interventions that included staff assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Resident 46 required the extensive assistance with staff for hygiene and grooming. Review of quarterly MDS assessments (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 27, 2025, and July 28, 2025, indicated that Resident 46 needed substantial/maximal assistance with personal hygiene. Observation of Resident 46 again on August 1, 2025, at 9:38 AM with Employee 2 (licensed practical nurse) revealed that the fingernails of his bilateral hands continued to extend beyond the tips of his fingers, darkened substances remained underneath several fingernails, and a red substance (presenting as dried blood) was noted under the fingernails of his right hand. A skin injury one and 1.5 inches long was observed with dried, smeared, blood on Resident 46's left forearm. The surveyor reviewed the concern regarding hygienic care of Resident 46's fingernails during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on August 1, 2025, at 1:50 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure the highest practicable care regarding a pacemaker for one of 18 residents reviewed (Resident 44). Findings include: Clinical record review for Resident 44 revealed that the facility admitted him on April 4, 2023. Diagnoses listed for Resident 44 upon his admission to the facility included the presence of a cardiac pacemaker (surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). Review of Resident 44's clinical record revealed a current care plan for cardiac disease related to coronary artery disease (a condition where the arteries supplying blood to the heart narrow due to plaque buildup restricting blood flow), congestive heart failure (the heart does not pump blood well enough causing fluid to accumulate), hypertension (high blood pressure), and a pacemaker. The listed interventions included instructions to perform pacemaker checks; however, there was no intervention related to a pacemaker machine or method used to perform pacemaker checks. Clinical record review for Resident 44 revealed no evidence of a current physician's order for pacemaker monitoring until July 31, 2025, after the surveyor brought it to the facility's attention during a meeting with the director of nursing, nursing home administrator, and Employee 1, (registered nurse, director of clinical operations) on July 30, 2025, at 2:30 PM. Interview with the Director of Nursing and Nursing Home Administrator on July 31, 2025, at 2:20 PM confirmed that there was no order for Resident 44's pacemaker checks prior to the surveyor bringing it to their attention on July 30, 2025. They also confirmed that they had no evidence that pacemaker checks were being completed for Resident 44. The facility failed to provide the highest practicable care regarding Resident 44's pacemaker. 28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.3(a)(e)(2) Verbal and telephone orders28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess a resident's bed system for potential accident hazards for one of 18 residents reviewed (Resident 15). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become trapped. FDA is recommending 60 mm (two and three-eighths inches) as an appropriate dimension for neck diameter. The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA concurs with the dimension of 318 mm (12.5 inches) to represent chest depth for the population vulnerable to entrapment and has used this dimension as the basis for its recommended dimensional limits. This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Zone seven is the space between the inside surface of the headboard or foot board and the end of the mattress. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. FDA recognizes this area as a potential for entrapment and encourages facilities and manufacturers to report entrapment events at this zone. Observation of Resident 15's room on July 30, 2025, at 10:17 AM revealed he was in his bed. Observation of Resident 15's bed system revealed that there were assist bars bilaterally at the head of his bed, a trapeze device mounted in the center of his bed, and there was a gap of six to eight inches between the top of his mattress and the headboard. Resident 15's bed system did not include a footboard. Clinical record review for Resident 15 revealed a GUAR-In Bed Positioning / Side Rail Evaluation dated July 10, 2025. The facility assessed Resident 15's bed positioning for safety. The document stipulated that the Gaps between head/foot boards and bed rails are within the FDA dimensional limits (<2-1/3 inches) and do not represent a risk for entrapment. (Devices may be used to decrease gaps/spaces); however, the document did not address the potential spatial concerns between the mattress and the headboard. Observation of Resident 15's room on August 1, 2025, at 9:32 AM with Employee 2 (licensed practical nurse) revealed he was in his bed. Employee 2 measured the space between the top of Resident 15's mattress to his headboard for a measurement of 10 inches. There was no footboard on Resident 15's bed and the mattress appeared to have slid distally within the bed system. The surveyor reviewed the above concern regarding the Zone seven gap within Resident 15's bed system during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 (registered nurse/director of clinical operations), on August 1, 2025, at 1:50 PM. The Director of Nursing indicated that Resident 15 may have had a footboard at one time on his bed; however, the facility was unable to provide documentation of when this bed system change occurred. The facility was unable to provide evidence of an assessment of Resident 15's bed system that included a review of the stability of the mattress positioning to ensure that potential sliding of the mattress did not present a gap size that presented a potential risk for entrapment. 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 the consultant pharmacist reported any irregularities to the attending physician (and the facility's medical director if applicable) and the Director of Nursing on a separate, written report; and that the attending physician documented a review and actions taken to address the identified irregularity in the resident's medical record for one of five residents reviewed for medication regime concerns (Resident 27).Findings include: Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on July 30, 2025, at 1:45 PM revealed that the facility's contracted consulting pharmacist reviews each resident's medication regime monthly and, unless listed on the document entitled, Listing of Residents Reviewed with No Recommendations, a resident has a separate report of the identified potential medication irregularity on which the attending physician documents a review and response. The interview indicated that the separate report would be scanned into the resident's electronic medical record under the miscellaneous section. Clinical record review for Resident 27 revealed that her name did not appear on the Listing of Residents Reviewed with No Recommendations, report for November 2024, December 2024, and March 2025. Resident 27's electronic medical record did not include a separate report from the consultant pharmacist for those months. Interview with the Director of Nursing on August 1, 2025, at 12:24 PM confirmed that upon her review of Resident 27's physical chart, there were no separate reports from the consultant pharmacist for November 2024, December 2024, or March 2025. Interview with the Director of Nursing on August 1, 2025, at 12:38 PM indicated that the consultant pharmacist included recommendations for Resident 27 to nursing staff on November 3, 2024, that read, Please update the Seroquel (antipsychotic medication) order to 25 mg (milligrams) daily. Per GDR (gradual dose reduction) in October it was decreased from 50 mg to 25 mg daily, within a list that included other residents' information. Although it is not in the scope of practice for licensed nursing staff to update a physician's order for a medication, the consultant pharmacist did not refer this recommendation to Resident 27's physician. The consultant pharmacist also did not document this information on a separate report for documentation of the monthly review in Resident 27's medical record. Interview with the Director of Nursing on August 1, 2025, at 12:38 PM indicated that the consultant pharmacist included recommendations for Resident 27 to nursing staff on December 8, 2024, that read, The resident is receiving Cholestyramine (medication that lowers fats, like cholesterol, in the blood). Please ensure periodic labs are conducted to monitor. Documentation of results should be accessible for review, within a list that included other residents' information. The list included a second entry that repeated, Please update the Seroquel order to 25 mg daily. Per GDR in October, it was decreased from 50 mg to 25 mg daily. Although it is not in the scope of practice for licensed nursing staff to generate orders for laboratory testing or update medication dosages, the consultant pharmacist did not refer these findings to Resident 27's physician on a separate report for documentation of the monthly review in Resident 27's medical record. A consultant pharmacist report dated February 3, 2025, requested that Resident 27's physician review Resident 27's use of Hydroxyzine (antihistamine that reduces the symptoms of itching, or hives, on the skin; it can also be used as a sedative to treat anxiety and tension) 50 mg at HS (hour of sleep) for a possible GDR or discontinuation. The physician did not document a review and response to this recommendation until more than a month later (dated March 5, 2025), which agreed to decrease the medication to 25 mg at HS. Due to the time lapse between the February 2024 consultant pharmacist review and Resident 27's physician's response in March 2025, the consultant pharmacist repeated the request for the facility to review Resident 27's Hydroxyzine medication for a possible GDR per a Consultant Pharmacist's Medication Regimen Review Recommendations Pending a Final Response, report generated for Outcomes Entered Between March 1, 2025, and March 5, 2025; however, the consultant pharmacist did not document these findings to Resident 27's physician on a separate report for documentation of the March 2025 monthly review in Resident 27's medical record. Interview with the Director of Nursing on August 1, 2025, at 1:20 PM confirmed that the only evidence a consultant pharmacist reviewed Resident 27's medication regime in March 2025, was the above-mentioned report, which listed several other residents' information and did not generate a separate report to a physician although the entry noted, Routed to: MD. A physician's order dated March 5, 2025, instructed staff to decrease Resident 27's Hydroxyzine medication to 25 mg at bedtime (after the consultant pharmacist's March 2025 review). Resident 27's physician did not complete a timely review and response to the consultant pharmacist's February 3, 2025, reported irregularity. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medical records were readily accessible to individuals performing health oversight activities for one of 18 residents reviewed (Resident 27). Findings include: The state survey agency entered the facility on July 29, 2025, at 9:00 AM and provided the Nursing Home Administrator the federal Entrance Conference Worksheet, which included the form entitled, Electronic Health Record (EHR) Information. Instructions on the form direct the provider to, Provide specific instructions on where and how surveyors can access the following information in the EHR (or in the hard if using split EHR and hard copy system) for the initial pool record review process. Surveyors require the same access staff members have to residents' EHRs in a read-only format. Clinical record review for Resident 27 revealed that the surveyor was unable to view three months of nurse aide documentation of the completion of tasks necessary for Resident 27's care (e.g., bathing, toileting assistance, bowel elimination records, incontinence care, behavior monitoring, oral hygiene, application of medical devices, etc.). Email communication to the Nursing Home Administrator on August 1, 2025, at 9:17 AM requested instructions regarding how the surveyors could independently review a month of nurse aide documentation (as reports run for licensed staff completion of treatments or medications) for a resident. The Nursing Home Administrator email response on August 1, 2025, at 11:05 AM indicated that she would print the nurse aide documentation that the surveyor requested. Interview with Employee 3 (licensed practical nurse) on August 1, 2025, at 12:50 PM revealed that he could view and print a Documentation Survey Report, that provided documentation by nurse aide staff of the care and services provided to Resident 27 for any month requested. Employee 3 printed this report for the surveyor at that time. The state agency surveyor was unable to view the same information independently without the intervention of facility staff. The facility failed to ensure that surveyors were provided the same medical record access staff members had to residents' EHRs in a read-only format. The surveyor reviewed the above concern with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on August 1, 2025, at 1:50 PM. 28 Pa. Code 211.5(b)(1)(2)(f)(i)-(xi)(i) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide professional dental services for two of two residents reviewed for dental concerns (Residents 27 and 46). Findings include: Observation of Resident 27 on July 30, 2025, at 10:32 AM revealed she was edentulous (without natural teeth). Interview with Resident 27 on the date and time of the observation revealed that she once had a full denture for her upper and lower jaws; however, Resident 27 alleged that staff took her lower denture, and she did not know when or where they took them. Review of Resident Evaluation documentation dated June 1, 2024, at 4:00 AM for a quarterly review revealed that she was mentally oriented to person and place; however, was noted to have current and a history of behaviors. Staff assessed Resident 27 as having a full upper denture plate and a full lower denture plate. and Resident 27 preferred her dentures only removed at night. An annual MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated August 2, 2024, indicated that the care area related to dental concerns triggered as Resident 27 had full upper and lower dentures during the review of July 27, 2024, to August 2, 2024. The annual MDS dated [DATE], and a quarterly MDS dated [DATE], revealed that Resident 27 was dependent on staff for oral hygiene. Oral hygiene is defined as the ability to use suitable items to clean teeth; dentures (if applicable). The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment. An electronic document entitled, Resident Evaluation V6, dated October 31, 2024, indicated that lower dentures were not applicable for Resident 27 (she did not have a lower denture at that time). A plan of care initiated by the facility on December 23, 2022, to address Resident 27's self-care deficit related to activities of daily living stipulated that Resident 27 required staff to Assist with daily hygiene, grooming, dressing, oral care and eating as needed. A plan of care to address Resident 27's edentulous condition (revised April 16, 2025) noted that Resident 27 had a full upper denture but no lower denture. The plan of care intervention for staff to assist with oral hygiene and dentures as needed was initiated December 27, 2022. The surveyor requested any documentation that the facility identified and addressed Resident 27's missing lower denture during interviews with the Nursing Home Administrator, Director of Nursing, and Employee 1 (registered nurse, director of clinical operations) on July 30, 2025, at 1:45 PM and July 31, 2025, at 2:00 PM. Interview with the Nursing Home Administrator on July 31, 2025, at 2:48 PM indicated that the Nursing Home Administrator confirmed that Resident 27 had an upper and lower denture; however, at some point, lost the bottom dentures but the facility did not know when. The Nursing Home Administrator indicated that there was no incident investigation or progress note to evidence when Resident 27 no longer had her lower denture between the dates of August 2, 2024, and October 31, 2024. The Nursing Home Administrator stated that Resident 27 exhibited a behavior of throwing her dentures at staff. Documentation by the facility's consultant professional dental provider dated January 6, 2025, indicated that Resident 27 was not a candidate for a lower ridge denture. Interview with Employee 1 on July 31, 2025, at 3:26 PM confirmed that the first assessment that indicated Resident 27 no longer had a lower denture was on October 31, 2024, and the facility had no evidence of an attempt to obtain professional dental services to replace the denture until January 6, 2025 (more than two months after). The facility was unable to provide a determination of when Resident 27 lost her lower denture within the three-month time between August 2, 2024, and October 31, 2024, despite Resident 27's dependence on staff for her oral hygiene daily. It was determined that the facility did not obtain timely professional dental services for a resident who lost their denture. Clinical record review for Resident 46 revealed that the facility admitted him on October 6, 2024, with Medicaid as a payment source for his admission to the facility. Observation of Resident 46 on July 30, 2025, at 10:58 AM revealed he had his fingers in his mouth pinching a tooth on his lower right jaw while repeating, can you take it out? Observation of Resident 46's mouth revealed he had missing and discolored teeth. Clinical record review for Resident 46 revealed no evidence of professional dental services provided since his admission to the facility (almost eight months). The surveyor requested any evidence of professional dental services for Resident 46 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 on July 30, 2025, at 1:45 PM. An admission MDS assessment dated [DATE], assessed Resident 46 has having no obvious or likely cavities or broken natural teeth. A plan of care initiated by the facility on March 27, 2025, indicated that Resident 46 had a dental or oral cavity health problem related to broken and missing teeth. Interventions listed in the plan of care included that the facility would refer Resident 46 to the dentist/hygienist for evaluation/recommendations regarding denture realignment, new fitting, teeth extraction, and repair of carious teeth. Interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 on July 31, 2025, at 2:00 PM confirmed that the facility had no evidence that Resident 46 received professional dental services since his admission in October 2024. The facility provided no evidence that Resident 46 or Resident 46's responsible party refused services from the facility's contracted dental provider. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15 Dental services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 14 residents reviewed (Resident 39) Findings include: Clinical record review for Resident 39 revealed a diagnoses list that included a history of muscle weakness. Resident 39's current care plan noted the resident was at risk for falls due to weakness. An intervention included having the call bell in reach. Observation of Resident 39 on October 11, 2023, at 11:28 AM revealed the resident was in bed. The resident's call bell was observed draped over a recliner that was positioned next to the bed. The call bell was four feet from the resident and not easily accessible. Observation of Resident 39 on October 13, 2023, at 10:44 AM revealed the resident was in bed. The resident's call bell was observed coiled up on the right arm of the recliner that was positioned next to the bed and not easily accessible. Interview with Employee 4, licensed practical nurse, on October 13, 2023, at 10:44 AM confirmed the finding and placed the call bell within Resident 39's reach and advised the call bells should always be on the residents. The above findings for Resident 39 were reviewed with the Nursing Home Administrator on October 13, 2023, at 12:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of one resident reviewed (Resident 3). Findings include: The policy entitled Abuse Policy, last reviewed on August 29, 2023, indicates that the facility describes an injury of unknow origin as an injury that was not observed by any person, cannot be explained by the resident, and a suspicious location not generally vulnerable to trauma. The policy does not specify how the facility will specifically rule out abuse when an injury of unknown origin occurs. Review of Resident 3's clinical record revealed a nursing care plan indicating that she needs the help of two staff members to use a mechanical lift to transfer her out of bed. Resident 3 is not self-ambulatory. A nursing note dated October 6, 2023, at 6:30 PM indicated that staff noted a bruise to the top of Resident 3's left foot measuring 5 cm (centimeters) by 4 cm. The note further described the bruise as green and blue (indicating an older bruise up to five days). Review of the facility's investigation into Resident 3's bruised left foot revealed a witness statement form indicating that for investigations regarding a bruise, the facility is to collect staff statements from the previous three days prior to its discovery. The facility only collected two staff members on the same shift it was discovered, one who reported it and another who didn't see it. There was no documented evidence to indicate the facility collected staff statements for the three days prior to Resident 3's discovery of her bruise. There was also no other documented evidence to indicate the facility thoroughly investigated the possible cause of the bruise to rule out the potential for abuse and/or neglect. Interview with Employee 1, consultant, on October 13, 2023, at 11:00 AM confirmed the above findings for Resident 3. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

**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 provide the highest practicable care regarding the care of a pacemaker for one of one resident reviewed with a pacemaker (Resident 12). Findings include: Clinical record review revealed Resident 12 was admitted to the facility on [DATE]. Clinical record review of Resident 12's diagnoses list included a left bundle branch block (a disease that impacts or disrupts the electrical impulse that causes the heart to beat). Clinical record review for Resident 12 revealed hospital documentation that noted the resident had a pacemaker implanted in October 2018. A current care plan for Resident 12 indicated the resident had cardiac disease related to the left bundle branch block and an intervention included, pacemaker checks as ordered. A review of the current physician orders for Resident 12 revealed no current orders related to pacemaker checks; however, an order dated October 28, 2018, noted cardiology consult as needed. A review of Resident 12's clinical record revealed no pacemaker checks. An interview with the Nursing Home Administrator on October 13, 2023, at 12:45 PM, and Employee 2, licensed practical nurse, on October 13, 2023, at 1:00 PM reported Resident 12 refused the pacemaker check appointments. Upon the surveyor asking for documentation to support this, the only documentation provided by the facility was a form titled Resident Refusal of Appointment dated September 2, 2020, for a cardiology appointment and the reason for refusal noted Resident refusing to wear a mask to go on appointment. An interview with Employee 2 on October 13, 2023, at 1:13 PM revealed a box for a [NAME] device (a device used for remote follow-up after implantation of a pacemaker) was found with Resident 12's name in the supply room of the facility; however, the device was not in the box or visible in the resident's room. Employee 2 was further observed advising Resident 12 that the facility was going to make an appointment to get the pacemaker checked and the resident stated, Oh, ok. The facility failed to provide the highest practicable care regarding Resident 12's pacemaker follow-up checks and it was unclear when the last pacemaker check occurred. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on clinical record review, review of facility investigation, and staff interview, it was determined that the facility failed to thoroughly investigate an accident regarding an elopement and implement interventions to prevent recurrence for one of one resident reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed nursing documentation dated September 21, 2023, at 4:56 PM indicating that nursing staff called Resident 51's representative to discuss Resident 51's elopement. Nursing documentation dated September 21, 2023, at 5:08 PM indicated that Employee 5, cook, received a text message from a neighbor indicating that an older lady was standing in front of her house. v Employee 5 drove to the neighbor's house and found Resident 51 in front of the neighbor's garage. Employee 5 brought Resident 51 back to the facility in her personal vehicle at approximately 4:25 PM with no apparent injuries. Review of the facility's investigation into Resident 51's elopement revealed that according to witness statements, Resident 51 was last seen at the nursing station in her wheelchair around 3:30 PM, with her pressure sensor chair alarm in place. The investigation indicated that prior to Resident 51's elopement, her chair alarm did not sound. There was no documented evidence in the facility's investigation that the facility determined why Resident 51's pressure sensor chair alarm did not sound prior to her elopement, or that a witness statement was collected from Employee 5 who was a key staff member in Resident 51's elopement. A progress note included in Resident 51's elopement investigation from the Interdisciplinary Team effective September 22, 2023, indicated that the keypad to the door that Resident 51 exited was reactivated and staff education/disciplinary action for nurse aides on completing rounds and alarm checks. There was no documented evidence to indicate that the facility determined why the keypad to the door was not activated or not working, if the facility completed a facility wide sweep of other doors with alarms to ensure proper functioning, or that the facility performed staff education or disciplinary action regarding not completing rounds and alarm checks. Interview with Employee 1, consultant, on October 12, 2023, at 2:50 PM confirmed the above findings for Resident 51. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for three of three residents reviewed (Residents 13, 37, and 46). Findings include: Review of Resident 13's clinical record revealed that the facility transferred him to the hospital on August 8, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 13's transfer to the hospital. Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on June 20, 2023, and again on September 17, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 37's transfers to the hospital. Review of Resident 46's clinical record revealed that the facility transferred the resident to the hospital on August 31, 2023, at 7:50 AM. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 46's transfer to the hospital. Interview with Employee 3, social worker, on October 12, 2023, at 1:04 PM confirmed the above findings and indicated that she had not sent any transfer notices to the Office of the State Long-Term Care Ombudsman for any resident transfers. Employee 3 indicated that she was faxing the local Ombudsman office, but also could not provide documented evidence that it occurred. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

**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 develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 4, 42, and 49). Findings include: Clinical record review for Resident 4 revealed the facility admitted her on September 9, 2021, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of a significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 21, 2023, indicated that the facility assessed Resident 4 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 42 revealed the facility admitted her on March 12, 2021, with diagnosis including Dementia. A review of Resident 42's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 42's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 49 revealed the facility admitted her on February 25, 2022, with diagnosis including Dementia. A review of Resident 49's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 49's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Director of Nursing, Nursing Home Administrator, and Employee 1 (consultant) on October 12, 2023, at 11:30 AM. Further interview with Employee 1 on October 13, 2023, at 9:35 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 4, 42, and 49's dementia and cognitive loss. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to report an incident of resident neglect for one of five residents reviewed for fall concerns (Resident 7). Findings include: The Abuse Policy, last reviewed without changes on October 20, 2022, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or mental illness. Neglect is the unwilful act of not providing goods and services to a resident. Examples (not all inclusive) include the failure to follow the care plan. The facility ensures that any incidents of substantiated abuse are reported and analyzed and the appropriate corrective, remedial, or disciplinary action occurs in accordance with applicable local, state, or federal law. Staff members and persons affiliated with the facility will not knowingly fail to report an incident of mistreatment or other offense; and/or screen reports or withhold information to reporting agencies. The facility will electronically report to the Division of Nursing Care Facilities field office and call the area agency on aging all allegations of abuse, neglect, misappropriation, and exploitation, and/or suspicion of a crime within 24 hours of initial knowledge of any of the above incidents following policies and procedures outlined in the Electronic Reporting System manual. The PA Department of Health (PA-DOH) Event Reporting System (ERS) NCF (Nursing Care Facilities) Facility Manual Effective November 1, 2012, defines neglect as the deprivation by a caretaker of goods or services, which are necessary to maintain physical or mental health. All reports under this category require a PB22 (Provider Bulletin 22, documentation of an investigation of an allegation of abuse and/or neglect) and should be reported through ERS to DOH, and your local area agency on aging (verbal notification and follow up with written report - may use the PB22). Interview with Resident 7's daughter on November 7, 2022, at 1:51 PM revealed that the facility informed her that her mother almost fell but, .they (staff) caught her, during a transfer for care. Resident 7's daughter stated that the facility told her that they changed the lift they were utilizing to prevent future fall recurrence for Resident 7. Review of Resident 7's [NAME] (electronic system accessible to nurse aide staff to record resident care needs) for transfer instructions dated August 31, 2022, noted Resident 7 required a stand lift and two staff for transfers. Clinical record review for Resident 7 revealed nursing documentation dated September 1, 2022, at 7:30 AM that a nurse aide was transferring Resident 7 from her bed to her wheelchair utilizing an assist of one staff when Resident 7 was lowered to the floor. Resident 7 initially stated that her back hurt; however, when additional staff arrived, Resident 7 stated that, everything hurt. Plans of care developed by the facility to address Resident 7's risk for falls and a self-care deficit for activities of daily living instructed that Resident 7 required a front wheeled walker, gait belt, and the assistance of two staff to transfer from her bed to her chair and from her chair to her bed since August 3, 2021. Review of the facility's investigation of Resident 7's fall on September 1, 2022, revealed the facility determined that staff failed to have the necessary staff present (two staff) during the transfer. The investigation did not indicate that staff utilized the appropriate stand lift as per Resident 7's [NAME] instructions during the transfer. The surveyor confirmed the above findings for Resident 7 during an interview with the Nursing Home Administrator and the Director of Nursing on November 9, 2022, at 2:00 PM. The interview confirmed that the facility did not report the above incident to the local field office of the Department of Health, or complete a PB22, although the staff failure to transfer Resident 7 per her plan of care contributed to her fall. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a)(d) Resident care plan 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 refer a resident with a newly diagnosed mental disorder for level II review for two of two residents reviewed for PASSRR (Pre-admission Screening and Resident Review) compliance (Residents 4 and 12). Findings include: The revised PA-PASRR-ID form (PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated September 1, 2018, lists examples of serious mental illness including schizophrenia, psychotic disorder, mood disorder, bipolar, and depression. The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status). Clinical record review for Resident 4 revealed a PASARR (federally required assessment that prevents individuals with mental illness, intellectual disability, or a related condition from being admitted to nursing facilities until a full assessment is made and the least restrictive, most appropriate person-centered services are recommended to meet the individual's medical and disability-related needs) form dated September 10, 2021, that identified anxiety disorder as the only mental health condition. Clinical record review for Resident 4 revealed a new diagnosis of Psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality) added to her diagnosis list on May 11, 2022. Clinical record review for Resident 12 revealed a PASARR dated September 25, 2021, with major depressive disorder and unspecified mental disorder due to known physiological condition as the only mental health conditions (mental disorders due to known physiological conditions such as vascular dementia [brain damage related to a stroke], amnestic disorder [memory loss], or delirium [disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings], related to known cause). Further clinical record review revealed that a diagnosis of schizophrenia was added to Resident 12's diagnosis list on October 6, 2021. Interview with the Nursing home Administrator and Director of Nursing on November 9, 2022, at 2:15 PM related to Resident 4 and Resident 12's new diagnosis, confirmed that the facility did not add their new mental health condition to the PASSAR, and the reviewing agency was not notified of the new diagnosis to determine if a PASSAR level two review needed to be completed. There was no documented evidence that the facility notified the appropriate agencies regarding Resident 4 and 12's new mental health diagnosis. 483.20(e)(1)(2) Coordination of PASSAR and Assessments Previously cited 11/19/21 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.16(a) Social services

Based on clinical record review, review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to provide the highest practical care to promote pressure ulcer healing for one of two residents reviewed (Resident 25). Findings include: The facility policy entitled Pressure Injury/Skin Breakdown Clinical Protocol Playbook last reviewed without changes on October 20, 2022, revealed the purpose is to assist the facility to implement interventions to prevent pressure ulcers and/or enhance the wound healing process, to accurately assess/monitor a residents risk for alteration in skin integrity, to maintain and promote healthy skin integrity of residents, and to establish guidelines for the prevention and treatment of pressure sores. The interdisciplinary team will develop a plan of care based on findings and identified risks and if a pressure ulcer exists, a care plan will be developed for the management of the existing pressure ulcer/injury. The physician will assist staff to determine etiology of the skin alteration. Although poor nutritional status is associated with increased risk of pressure injury development, no specific nutritional supplements have been proven conclusively to prevent or heal pressure injuries. Clinical record review for Resident 25 revealed a progress note dated August 30, 2022, at 5:36 AM that indicated the nurse aide was providing care and noted an open area on the sacral split. The area was cleansed, Puracol (a collagen wound dressing) applied and covered with Opti foam (a highly absorbent wound dressing). A wound evaluation form completed on September 1, 2022, indicated the area was moisture associated skin damage (MASD). The wound measured 1.5 cm length, 0.5 cm width, and 0.1 depth. A nursing progress note dated September 9, 2022, at 1:54 PM revealed that the center of the wound on Resident 25's sacrum had a large amount of white exudate (fluid that has seeped out of blood vessels) and a foul odor. The area around the wound was red. A nursing progress note dated September 11, 2022, at 6:05 AM revealed that Resident 25's urine was dark brown and concentrated with a foul odor and that the sacrum dressing was intact. A note was sent to the physician asking for a urine culture and wound culture as the sacral wound was noted to have a foul odor on the previous shift. The wound culture was obtained on September 12, 2022, at 5:36 PM. A progress note dated September 15, 2022, at 10:15 AM revealed the sacral wound was red, warm, with serous (a clear thin watery drainage sometimes yellowish or brownish in appearance) drainage and painful to Resident 25 during the assessment. A wound evaluation on the same day revealed that the area was now an unstageable (an ulcer that the depth is obscured by slough in the wound bed), and the wound was bigger as it now measured 4.5 cm length, 5.5 cm width and 0.2 cm depth. Resident 25's physician ordered meta honey (a gel to treat wounds) and Opti foam to the sacral wound. On September 16, 2022, at 1:33 PM new orders for Cipro (an antibiotic) 500 milligrams two times a day for 14 days and Keflex (an antibiotic) 500 milligrams four times a day for 14 days, were received as a response to the wound culture report that showed gram positive cocci (bacteria). A nursing progress note dated September 17, 2022, at 2:01 PM revealed that when the sacral wound dressing was changed there was a medium amount of purulent (thick yellowish) drainage noted, the wound continued to have an odor, and there was slough visible. A progress note dated October 4, 2022, at 1:42 PM revealed that the treatment to Resident 25's sacral wound was changed to a collagen dressing. A progress note on this same day at 11:43 PM revealed that the dressing was changed, and the wound center was yellow/white and there was light grey discharge on the old dressing. No odor noted. A nursing progress note date October 18, 2022, at 5:26 PM revealed that the physician added ProSource to promote nutritional supplement to promote healing and ordered a consult with the wound clinic. A nursing progress note dated October 25, 2022 at 2:39 PM revealed that Resident 25 went to wound clinic and new orders were received for labs, a ROHO cushion to chair, resident not to be out of bed anymore that two hours at a time, and the treatment was changed to equal parts of Triamcinolone (a cream used to treat various skin conditions) 1%, Clotrimazole (a cream used to treat skin fungal infections) 1%, and Calmoseptine (helps to protect and heal skin irritations) to peri wound with Santyl (wound dressing) to open area, cover with 1/4 strength Dakin's (a strong topical antiseptic used to clean infected ulcers) moisten gauze, ABD (a gauze pad used to absorb discharges from heavily draining wounds) pad, and mefix tape (a dressing retention tape that securely sticks dressings to skin) daily and as needed for soilage. The wound clinic consult form indicated that the wound was a pressure ulcer, and the most important intervention was to relieve the pressure. A nursing progress note dated October 26, 2022, at 1:33 PM revealed that the ROHO (a flotation cushion used to relieve pressure) cushion was applied to Resident 25's chair and an air mattress was applied to his bed. Wound evaluations completed on September 20, 2022, of Resident 25's sacral pressure ulcer revealed that the wound measured 4.5 cm length, 5.5 cm width and 0.1 cm depth. A wound evaluation on September 27, 2022, and October 4, 2022, revealed that the wound decreased in size and measured 2.5 cm length, 4.5 cm width, and 0.1 cm depth. There was no wound evaluation completed from October 4, 2022, until October 17, 2022. On October 17, 2022, the wound increased in size and measured 3.2 cm length, 4.5 cm width, and 0.1 cm depth. Observation of Resident 25's sacral ulcer on November 10, 2022, at 9:04 AM revealed a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) clean pressure ulcer with no odor and a small amount of serous drainage. Resident 25 had no complaints of pain but stated that the area burned. Review of Resident 25's current care plan revealed that there were no interventions implemented to relieve pressure from his sacral area, from September 15, 2022, when the wound was first identified as a pressure ulcer, until he went to the wound clinic on October 25, 2022. An interview with the Director of Nursing, Nursing Home Administrator, and Employee 4 (Registered Nurse, Wound Nurse, and Infection control nurse) on November 10, 2022, at 1:00 PM revealed that they implemented nutritional supplements, a wound clinic consult, and changed the treatment to the area as needed. They confirmed that there was no documented evidence that the facility initiated interventions to relieve the pressure on Resident 25's sacral wound after it was identified as a pressure ulcer on September 15, 2022, until October 26, 2022, when they received recommendations from the wound clinic. The facility failed to implement preventative pressure interventions to provide the highest practical care to heal a pressure ulcer for Resident 25. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, it was determined that the facility failed to prevent potential for resident injury for one of two residents reviewed for accident hazards (Resident 30). Findings include: Review of Resident 30's clinical record revealed a current care plan dated August 13, 2022, that indicated the resident had a potential for safety concerns and potential injury from hot liquids. An intervention list included a clothing protector with meals. Observation of Resident 30 on November 9, 2022, at 12:10 PM revealed the resident was sitting upright next to the bed eating lunch and had a dark liquid present on her food tray that was in a Styrofoam cup. There was no clothing protector present. Employee 1, nurse aide, was overheard at the bedside asking Resident 30 if she wanted a drink of her coffee on November 9, 2022, at 12:30 PM. There was no clothing protector present. An interview with Employee 1 regarding Resident 30 on November 9, 2022, at 12:32 PM revealed that Employee 1 was not aware that the resident had a care planned intervention of using a clothing protector with meals. A concurrent review of the [NAME] with Employee 1 for Resident 30 revealed that the intervention for the clothing protector was not included in the [NAME]. The above information for Resident 30 was reviewed with the Nursing Home Administrator and Director of Nursing on November 9, 2022, at 2:14 PM. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, select facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed for respiratory concerns (Resident 8). Findings include: Review of the policy titled, Oxygen Administration, last reviewed without changes on October 20, 2022, revealed a purpose to provide guidelines for safe oxygen administration. A step of the procedure indicates to turn on the oxygen and, unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute (LPM). A review of the current physician orders dated June 13, 2022, instructed staff to apply oxygen to Resident 8 as needed for an oxygen saturation (SPO2; percentage level of oxygen in the body carried by the red blood cells) less than 91 percent as needed for shortness of breath. The order did not indicate a flow rate. Review of the current care plans for Resident 8 indicated that the resident has or is at risk for respiratory impairment related to chronic obstructive pulmonary disease (COPD; a chronic lung disease) and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). An intervention is to administer oxygen as ordered. Further review of the care plans for Resident 8 revealed a care plan that indicated the resident had cardiac disease related to hyperlipidemia, cardiovascular disease, and hypertension and interventions included administer oxygen at 1 liter per minute at bedtime and administer oxygen as ordered. Observation of Resident 8 on November 7, 2022, at 11:06 AM and 1:27 PM revealed that Resident 8 was in her bed and was receiving supplemental oxygen via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose). The flow rate was set at 2 liters per minute. Observation of Resident 8 on November 8, 2022, at 10:20 AM revealed the resident was in her bed and receiving supplemental oxygen via nasal cannula at a setting of 1 liter per minute. Observation of Resident 8 on November 10, 2022, at 10:13 AM revealed the resident was in her bed and receiving supplemental oxygen via nasal cannula at a setting of 2 liters per minute. Clinical record review of the documented oxygen saturations (found in the vital signs section of the record) for Resident 8 from September 4, 2022, to November 8, 2022, revealed that the resident's documented oxygen saturation ranged from 94 percent to 100 percent. There was no documented evidence that the oxygen saturation went below 91 percent, which per the physician order indicated a need for oxygen via the nasal cannula. Clinical record review of Resident 8's Medication Administration Record (MAR) respiratory screening for October 2022 and November 2022, revealed no documented cough or shortness of breath. Clinical record review of Resident 8's Treatment Administration Record (TAR) for October 2022 and November 2022, revealed a section for documenting the oxygen administration as needed for the oxygen saturation level less than 91 percent as needed for shortness of breath. The section was blank with no documentation that the oxygen was being administered. The above findings for Resident 8 were reviewed with the Nursing Home Administrator and Director of Nursing on November 10, 2022, at 1:15 PM. The Director of Nursing verbalized that the physician order for oxygen would have to be clarified. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on select facility policies and procedures, observations, and staff interviews, it was determined that the facility failed to securely store resident medications on one of one nursing units (Main Nursing Unit). Findings include: Review of the policy titled, Storage of Medications, last reviewed without changes on October 20, 2022, revealed that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel or pharmacy personnel. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation of the Main Nursing Unit revealed two storage areas that included the medication storage room and the treatment room. Observation of the medication storage room located behind the nurse's station on the Main Nursing Unit on November 7, 2022, at 2:28 PM revealed the door was open. The surveyor was able to walk into the storage area unattended and observed multiple medications including partially used blister packs in a plastic bin on the counter in the corner of the room. There were also two bottles of melatonin (a medication used to help with sleep) unattended on the counter. A black medication refrigerator was also observed with a small padlock; however, the lock was left open and not secured. There were no staff observed in the medication storage room or at the adjacent nurse's station. Observation of the treatment room on November 7, 2022, at 2:30 PM revealed the door required a code to be entered into a keypad for access when the door is closed. Upon entry into the room, observed were several plastic bins with drawers stored under a countertop. These drawers were easily accessible, and a container of Levofloxacin (antibiotic) 500 mg was observed unsecured. The other drawers held various intravenous fluids. An interview with Employee 1, nurse aide, on November 9, 2022, at 9:15 AM revealed that Employee 1 was able to provide the surveyor with the access code (the room required a code to be entered into a keypad for access when the door is closed) to the medication storage room on the Main Nursing Unit. The surveyor was concurrently able to access the medication room with the code provided by Employee 1. An interview with Employee 6, licensed practical nurse, on November 9, 2022, at 1:38 PM revealed that only the licensed staff should have access to the medication room. Employee 6 further reported that the nurse aides do enter the medication storage room, but they should be with a nurse. A plastic bin was observed unsecured on a countertop in the corner of the medication storage room. The bin held various medications, which included: Sertraline (used to treat anxiety and depression), Aripiprazole (an antipsychotic medication), nitroglycerin (used to help relieve chest pain), esomeprazole (used to treat certain stomach and esophagus disorders), solifenacin (used to treat bladder problems), carvedilol (used to treat high blood pressure and heart failure), fluconazole (used to treat fungal and yeast infections), cefdinir (used to treat bacterial infections), mirtazapine (used to treat depression), ibuprofen (used to treat mild to moderate pain), novolog (a type of insulin to treat high blood sugar), albuterol (used to treat wheezing and shortness of breath), and erythromycin (a type of antibiotic). Further review of the medication storage room revealed a cupboard with a built-in lock. The cupboard was open and revealed additional medications that included: melatonin, ferrous sulfate (iron supplement), iron (used to treat low iron and a low number of red blood cells in the body), calcium, vitamin C, and vitamin D. Observation of the medication storage room on November 9, 2022, at 1:40 PM revealed the black medication storage refrigerator was not secured by the padlock and Employee 6 was able to open it. A concurrent interview revealed it was supposed to be locked. The refrigerator held multiple medications such as gabapentin (used to treat seizures and nerve pain) and multiple insulins. The above information was reviewed in an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 9, 2022, at 2:00 PM. The NHA and DON reported that the medication storage room and treatment room should be closed, and only authorized or licensed staff should have access. The DON further reported that the medication found in the plastic bin in the medication storage room is for return to the pharmacy and is inventoried so the facility or the pharmacy would know if something is missing. However, anyone accessing the medication storage room would have access to those medications. Further observation on November 9, 2022, at 2:38 PM revealed Employee 7, housekeeping and laundry supervisor, was able to access the treatment room located on the Main Nursing Unit. Further observation on November 10, 2022, at 11:52 AM, revealed that Employee 8, nurse aide, was able to access the treatment room located on the Main Nursing Unit in search of a resident's electric razor. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(i) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to obtain timely routine dental services for one of two residents reviewed for dental concerns (Resident 29). Findings include: Interview with Resident 29 on November 7, 2022, at 12:05 PM revealed that he has had his current denture set since 1975. Resident 29 stated that he was fitted for new dentures in January 2022; however, he was still waiting for the new set of dentures. Nursing documentation dated January 21, 2022, at 10:32 AM indicated that the facility's consulting dental provider saw Resident 29 and impressions were taken for upper and lower full dentures. The surveyor requested all documentation pertaining to consulting dental visits for Resident 29 during the 2022 calendar year during an interview with the Nursing Home Administrator and the Director of Nursing on November 8, 2022, at 1:30 PM. Interview with the Nursing Home Administrator and the Director of Nursing on November 9, 2022, at 2:00 PM revealed that the facility could not provide documentation of Resident 29's treatment by the consulting dental provider on January 21, 2022. The information provided by the facility did not begin until June 7, 2022. Documentation by the facility's consulting dental provider dated June 7, 2022, indicated that Resident 29 presented for an upper and lower complete denture and that impression materials were used. Documentation by the facility's consulting dental provider dated July 7, 2022, again indicated that Resident 29 presented for an upper and lower complete denture and that impression materials were used. The interview with the Nursing Home Administrator and the Director of Nursing on November 9, 2022, at 2:00 PM confirmed that Resident 29 has been waiting for almost 10 months for a new set of dentures. 483.55(b)(1)-(5) Routine/emergency Dental Srvcs in Nfs Previously cited deficiency 11/19/21 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.15(a) Dental services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview, it was determined that the facility failed to maintain accurately documented medical records for one of 15 residents reviewed (Residents 32). Findings include: Review of Resident 32's clinical record revealed the [NAME] (an electronic device that includes pertinent resident information used for care) indicated that the resident was to have a bed alarm and documentation noted to select yes or no if the bed alarm was in place and functioning. Review of Resident 32's current care plan indicated the resident was at a risk of falls due to a history of falls, impaired balance, poor coordination, and unsteady gait. The care plan did not indicate a bed alarm as an intervention. Observation of Resident 32 on November 10, 2022, at 11:40 AM revealed the resident was in bed. There was no observed bed alarm as indicated by the [NAME]. A concurrent interview with the Director of Nursing (DON) confirmed there was no bed alarm. The DON reported that the alarm, Must have been discontinued because the resident was made independent. A review of the physical therapy notes dated September 21, 2022, at 3:52 PM revealed the resident was going to be upgraded to independent on unit with FWW (front wheeled walker) today. Documentation for Resident 32 provided by the facility revealed the bed alarm was initiated on August 22, 2022, and resolved with a revision date noted as September 28, 2022. The intervention noted as resolved was listed as pressure alarming bed alarm. A review of the task documentation for Resident 32 from October 12, 2022, to November 9, 2022, revealed that staff were documenting each day on multiple shifts that the bed alarm was in place and functioning. This included the day of November 7, 2022, at 10:06 AM, which is the day the surveyor observed no alarm present in the room. The [NAME] was not updated to reflect the changes of the resolved bed alarm. The above information for Resident 32 was reviewed in an interview with the Director of Nursing on November 10, 2022, at 11:40 AM upon confirmation with the DON that the resident did not have an alarm currently in place and the task was previously resolved. 28 Pa. Code 211.5(h) Clinical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medical records reflected emergency medical care wishes for three of five residents reviewed for advance directive concerns (Residents 28, 52, and 12). Findings include: The facility policy entitled, Advance Directives, last reviewed without changes on [DATE], indicated that advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The facility will determine the decision-making capacity of the resident and invoke the decisions of the legal representative if appropriate to the situation; and document specifically what the resident/representative is refusing. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy definitions included: Do Not Resuscitate - indicates that in case of respiratory or cardiac failure, no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used Other Treatment Restrictions - indicates that the resident/representative does not wish for the resident to receive certain medical treatments. Examples include, but are not restricted to, respiratory intubation (insertion of a tube in the airway to supply artificial respirations). The POLST (Pennsylvania Orders for Life-Sustaining Treatment, form designed to record a resident's treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) form utilized by the facility stipulated that to follow the orders, an emergency medical service provider must have an order from his/her medical command physician. This is an order sheet based on the person's medical condition and wishes at the time the orders were issued. Clinical record review of Resident 28's physical chart revealed a POLST signed by Resident 28's physician on [DATE], and Resident 28, that stipulated do not resuscitate (DNR) and do not intubate (DNI) in the event of a medical emergency. Review of Resident 28's electronic medical record (EMR) revealed no additional orders from Resident 28's physician pertaining to treatment in the event of a medical emergency (Resident 28 could receive CPR and intubation in the event of a medical emergency). Review of plans of care developed by the facility on [DATE], for Resident 28 revealed a plan of care that stipulated Resident 28 had an advanced directive that implemented Full Code (CPR, chest compressions, and artificial breathing assistance upon death in the event of a medical emergency/attempt resuscitation) care planning. The surveyor reviewed the absence of an EMR physician's order to implement Resident 28's emergency care wishes during an interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 1:30 PM. The surveyor reviewed the inconsistencies between Resident 28's POLST directives, electronic plan of care, and electronic physician orders with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:00 PM. Clinical record review for Resident 52 revealed EMR physician orders that instructed staff to implement Full Code treatment in the event of a medical emergency, and there were no other directions specified for the order. Review of Resident 52's physical chart revealed a POLST form signed by Resident 52's physician on [DATE], that indicated Resident 52's wishes were to receive CPR; however, Resident 52 should not be intubated. The surveyor reviewed the discrepancy between Resident 52's physician order in his EMR with his signed POLST wishes that limited interventions during an interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 1:30 PM. A physician's order dated [DATE], at 1:55 PM (following the surveyor's questioning) revised Resident 52's advance directive order to read, Full Code Limited additional interventions DNI, no advanced airway interventions or mechanical ventilation. Clinical record review for Resident 12 revealed a physician's order dated [DATE], that indicated he was a full code. Further clinical record review revealed no evidence of an advance directive form, POLST, or a progress note indicating that a conversation occurred with the resident and/or responsible party regarding advance directives and his wishes. The facility provided the surveyor with a POLST form on [DATE], at 10:19 AM that indicated the resident wanted cardiopulmonary resuscitation if he has no pulse and is not breathing. The form was dated [DATE], the day after the surveyor inquired about Resident 12's advance directives. Interview with Director of Nursing at 12:30 PM revealed that she did not have evidence of a conversation occurring with the resident/responsible party and the facility staff to coincide with the full code order dated [DATE]. 28 Pa. Code 201.29(a)(d) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding COVID-19 testing for four of four residents observed (Residents 8, 30, 32, and 38), COVID-19 isolation precautions for one of seven residents reviewed for infection control concerns (Resident 28), and equipment handling for one of two residents reviewed for an indwelling catheter (Resident 52). Findings include: The CMS QSO-20-38-NH, revised September 23, 2022, Additional Policy, and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, noted the following: Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures. The specimen should be collected and, if necessary, stored in accordance with the manufacturer's instructions for use for the test and CDC guidelines. During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. The Centers for Disease Control and Prevention (CDC), Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, updated July 15, 2022, noted that healthcare providers collecting specimens or working within six feet of patients suspected to be infected with SARS-CoV-2 (COVID-19) maintain proper infection control and use recommended PPE, which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown. An interview with the Nursing Home Administrator on November 7, 2022, at 9:30 AM revealed the facility was in outbreak status due to COVID-19 positive residents and staff and routine testing was being done on residents. Observation of COVID-19 testing on November 9, 2022, starting at 9:49 AM revealed Employee 5, registered nurse, collecting specimens for testing via nasal swabs on Residents 8, 30, 32, and 38. Employee 5 was observed collecting the swabs without wearing a protective gown. The above information was reviewed in an interview with the Nursing Home Administrator and Director of Nursing on November 10, 2022, at 1:15 PM. Observation of Resident 28's room on November 7, 2022, at 12:22 PM revealed the doorway to enter his room was covered with zippered plastic; and a plastic bin outside the doorway indicated that personal protective equipment (PPE, typically gloves, gowns, eye protection, and face masks) was necessary to enter the room. A sign on the wall above the PPE bin indicated that the donning/doffing area must be closed at all three zippers at all times; however, the plastic covering the doorway contained only one zipper. The sign indicated that you must sign the entry log with the time of entry every time you go in the room; however, there was no entry log present in the area. The first instruction was to sanitize hands for at least 20 seconds; however, there was no handwashing materials or alcohol-based sanitizer in the immediate area of Resident 28's room. The sign indicated that staff were to doff personal eye protection and personal N95 mask (although there was no stock of masks to don) before entering the room; however, there was no trash receptacle or instructions where to dispose of the mask and/or eye protection. Observation of the plastic bin outside Resident 28's room door on November 8, 2022, at 10:09 AM revealed that the bin did not contain any isolation gowns or N95 masks. The sign instructions included to don full PPE before entering and to discard gloves, N95, and eye protection after the visit in the room. Interview with Resident 28 on November 8, 2022, at 10:15 AM revealed that he knew that he tested positive for COVID-19 and was on special isolation precautions. Upon completion of the interview with Resident 28 on November 8, 2022, at 10:42 AM, the surveyor noted only one red bin to discard the reusable isolation gown; however, there was no covered bin/trash receptacle to discard the gloves, eye protection, and/or N95 mask. There was no sign on the inside of the room that would include PPE doffing instructions. There was no PPE available inside the room to replace the N95 or eye protection that was to be removed per the instructions on the sign outside the room door. Observation of Resident 28's PPE setup and interview with Employee 4 (assistant director of nursing/infection control prevention coordinator) on November 10, 2022, at 10:20 AM indicated that the PPE donning/doffing instructions at the doorway was outdated; and was only appropriate when the facility had a Red Zone (area that included specific rooms isolated from the rest of the facility to quarantine COVID-19 positive cases) with a delineated doffing/donning area between two zippered compartments before entering that area's hallway. Employee 4 confirmed that there is no longer an entry log for someone to sign as per the instructions. Employee 4 confirmed that Resident 28's room was not equipped with three bins as necessary: one for garbage, one for washable gowns, and one for face shields to clean and reuse. Employee 4 also confirmed that the doorway to enter the room was not equipped with a second bin that would contain N95 masks and a place for someone to bag and store a personal face shield or personal goggles as instructed in the directions. The outside area of Resident 28's door was also not equipped with a trash receptacle to remove and discard an N95 mask after exiting the donning/doffing area as instructed in step 12 of the sign. There were no new N95 masks available to don as instructed in step 14 of the sign. Employee 4 confirmed that there was no alcohol sanitizer in the nearby area of Resident 28's doorway to perform hand hygiene after removing gloves and touching the zippered compartment to enter/exit the room. Review of the facility's policy entitled, Urinary Leg Drainage Bags, last reviewed without changes on October 20, 2022, revealed that the purpose of the procedure was to provide guidelines to decrease the likelihood of urinary tract infections associated with the intermittent use of leg drainage bags with Foley catheters. The regular straight drainage bag may be reconnected only if it appears that the integrity of the system has been maintained. Steps in the procedure include to carefully remove the sterile cover over the connection tip on the urinary leg drainage bag and place the cover over the connection tip of the straight drainage bag. Empty straight drainage bag and measure the urine. Keep the drainage bag in a safe place where it will not be mishandled. If there is reason to believe the integrity of the system has not been maintained, obtain a new drainage bag. Clinical record review for Resident 52 revealed current physician orders to unplug a Foley catheter (tubing inserted through the urethra into the bladder for the purpose of draining urine) four times a day and drain Resident 52's bladder in place of utilizing a collection bag. The instructions included to connect the Foley catheter to a drainage bag at night. Observation of Resident 52's room on November 7, 2022, at 2:36 PM revealed a Foley catheter collection bag with tubing hanging from Resident 52's walker. The end of the tubing was not capped and exposed to potential environmental contaminants. Interview with Resident 52 on the date and time of the observation revealed that he believed that staff lost the cap (the sterile cover over the tubing's connection tip); and that staff told him that the facility did not have any other collection bags available. Resident 52 stated that he brought the collection bag currently in use from home. Observation of Resident 52's room on November 8, 2022, at 12:01 PM again revealed the Foley catheter collection bag hanging from his walker with no cap on the end of the tubing to protect it from potential environmental contaminants. There was approximately 500 milliliters of yellow liquid in the collection bag. Observation of Resident 52's room with the Director of Nursing on November 8, 2022, at 12:10 PM confirmed the above observation of the collection bag storage. The Director of Nursing questioned Resident 52 who reiterated that a nurse lost the cap to the tubing, some time ago, that it was, .rolling around in here (his room) somewhere. Resident 52 stated that he was worried about urinary tract infections from the improper storage of the tubing. The Director of Nursing informed Resident 52 that she would obtain a new collection bag setup at that time. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of the facility's assessment tool, nurse aide in-service records, and staff interview, it was determined that the facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for three of three nurse aides reviewed (Employees 1, 2, and 3). Findings include: Review of the current facility-wide assessment tool (document that determines what resources are necessary to care for the facility's residents competently) revealed that services and care offered based on residents' needs included activities of daily living (e.g., bathing/showers and eating). Staff training/education and competencies included that staff is in-serviced during orientation, annually, and as needed on infection control, fire safety, blood borne pathogens, abuse/neglect/mistreatment, elopement, advance directives, corporate compliance, resident care, and HIPPA (resident confidential information) via online training. The facility's current assessment tool did not stipulate that the ongoing coordinated educational program would include dementia management training or (in compliance with Pennsylvania Code 201.20. Staff development) would include accident prevention, disaster preparedness, resident psychosocial needs, restorative nursing techniques, and resident rights (including personal property rights, privacy, and preservation of dignity). The surveyor requested competencies pertaining to ADL care and appropriate feeding techniques and evidence of annual in-service education for three nurse aide staff as follows: Employee 1, hire date May 6, 2013 Employee 2, hire date May 2, 2012 Employee 3, hire date June 22, 2016 Interview with the Nursing Home Administrator on November 10, 2022, at 9:15 AM, confirmed that the facility had no evidence that the nurse aides reviewed completed the requested competencies or a minimum of 12 hours of training in the past year. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.19 Personnel policies 28 Pa. Code 201.20 (a)(c)(d) Staff development 28 Pa. Code 211.12(c) Nursing services