**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 a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 14 sampled residents. (Residents 17, 18) Findings include: Clinical record review revealed that Resident 17 was admitted to the facility on [DATE], and had diagnoses that included dementia and a lumbar spine compression fracture. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident received daily scheduled pain medication. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated April 19, 2024, noted that the resident's pain was to be addressed in the care plan. There was no evidence that interventions to address Resident 17's pain were included in the current care plan. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], and had diagnoses that included cognitive communication deficits and anxiety. The MDS assessment dated [DATE], noted that the resident had impaired cognition. The MDS CAA summary dated May 11, 2024, noted that the resident's cognitive loss and dementia were to be addressed in the care plan. There was no evidence that interventions to address Resident 18's cognitive loss and dementia were included in the current care plan. In an interview on October 3, 2024, at 11:05 a.m., the Nursing Home Administrator confirmed the above care areas were not addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the skilled unit kitchen and the main kitchen of the dietary department. Findings include: Review of the facility's policy entitled, Food Storage, dated August 13, 2024, revealed that when a food item was opened, a use-by date must be noted on the item and the food was to be discarded after this date. Observations during the tour of the skilled unit kitchen on October 1, 2024, at 9:50 a.m., revealed the following: The ice machine had a white substance on the outside of the lid. Inside the ice machine there was a dark substance along the front of the plastic ice shield. The can opener had a black dried substance on the blade. There was a hair on the can opener. Observations during the tour of the main kitchen on October 1, 2024, at 10:15 a.m., revealed the following: In Walk-In Cooler 1 there was an opened package of lunch meat with a use-by date of September 28, 2024, and an opened container of mozzarella cheese with a use-by date of August 31, 2024. In Walk-In Cooler 2, there were two large pans of bread stuffing, two opened containers of sliced turkey, an opened package of unsliced turkey and a pan of pureed sausage that were not dated. In an interview on October 1, 2024, at 10:30 a.m., the Executive Chef confirmed these items were for the Skilled Unit, and should have been dated, and were not. 28 Pa. Code 201.14(a) Responsibility of licensee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to provide adequate supervision in order to prevent an elopement for one of two sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Elopements and Wandering Residents, dated May 24, 2023, revealed that the facility was to identify residents with potential and/or actual risk factors for elopement to protect the resident through development and implementation of safety interventions. Elopement occurs when a resident leaves the premises or safe area without authorization and/or the necessary supervision to do so. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included anxiety, cerebrovascular disease, dementia, and depressive disorder. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was independent with walking in the corridor with a walker. On November 27, 2023, at 10:26 p.m., a nurse noted that the resident was attempting to leave the unit. On December 23, 2023, at 9:07 p.m., the nurse noted that the resident had put her coat on and told staff she was going for a walk. She was observed attempting to open the B hall exit door. Resident 1 then walked down the hall towards her room and attempted to open the doors at the end of the hallway. On January 6, 2024, at 2:55 p.m., the resident ambulated with her walker from the common area to the end of C hall, pushed the fire exit door open, and exited the building. Documentation revealed that staff from the personal care unit observed the resident dressed in a coat and sneakers with her walker attempting to get back into the building. Staff from the skilled nursing unit was notified and brought the resident back inside the building. In an interview on January 12, 2024, at 1:45 p.m., the Assistant Nursing Home Administrator stated that Resident 1 pushed the fire exit door bar and eloped from the facility without staff knowledge. The facility failed to ensure adequate supervision for a resident who had exhibited exit-seeking behaviors. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for two of 12 sampled residents. (Residents 7, 16) Findings include: Review of the facility policy entitled, Incontinence - Assessment and Management, last reviewed August 14, 2023, revealed that facility staff was to complete a urinary incontinence assessment upon admission and whenever there was a change in a resident's urinary tract function. Staff would complete a quarterly screening and if there was a change in incontinence staff would implement a seven day toileting diary to determine a resident's voiding pattern for assistance in decision making and development of a toileting program. The type of urinary incontinence was to be identified in the care plan with specific interventions. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included parkinsonism and depression. A Bowel and Bladder Program Screener was completed on April 30, 2023, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated July 18, 2023, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Review of the current care plan revealed that Resident 7's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. Review of the MDS assessment, dated October 12, 2023, indicated that Resident 7 was incontinent of urine and was not on a scheduled toileting program. There was no documentation in the clinical record to support that the resident's urinary incontinence was assessed by the facility upon admission and upon a change in Resident 7's incontinence to determine if normal bladder function could be restored. There was no documented evidence that a seven day toileting diary was completed upon identification of a change in Resident 7's incontinence status or that a scheduled toileting program had been implemented. Clinical record review revealed that Resident 16 was admitted to the facility with diagnoses that included congestive heart failure and depression. A Bowel and Bladder Program Screener was completed on October 5, 2023, and indicated that the resident was a candidate for a scheduled toileting program. According to the MDS assessment, dated October 12, 2023, the resident needed assistance from staff for toileting, was frequently incontinent of urine, and was not on a toileting program. Review of the current care plan revealed that Resident 16's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. In an interview on November 8, 2023, at 12:45 p.m., the Assistant Nursing Home Administrator confirmed that there was no documented evidence that Resident 7's urinary incontinence had been assessed per facility policy or that toileting programs were implemented for Residents 7 and 16. 28 Pa. Code 211.12(d)(1)(5) Nursing services.