Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of eighteen residents reviewed (Resident 42). Findings include: Review of the facility policy titled, Medication Administration, with a last reviewed and revised date of February 2025, revealed, in step a., Proceed to resident's room and open resident's EMAR (electronic medical administration record)- pull out resident's medication packs. Review of Resident 42's clinical record revealed diagnoses that included diabetes (when the body either doesn't produce enough insulin or can't use insulin properly) and anxiety disorder (a group of mental health conditions characterized by excessive fear or worry, interfering with daily life and causing distress). Observation of Resident 42 on March 12, 2025, at 8:00 AM revealed resident 28 sitting a wheelchair in the dining room waiting to be served breakfast. Employee 1 (Licensed Practical Nurse) prepared Resident 28's oral medication and insulin for administration. Employee 1 then approached Resident 28, gave Resident 28 their oral medications, and then lifted Resident 28's shirt and injected Resident 28's insulin into the left side of her abdomen. Review of Resident 42's care plan failed to reveal a focus area or intervention that Resident 28 preferred to receive her medication in the dining room or in common areas. During an interview on March 13, 2025, at 10:28 AM with the Director of Nursing, she revealed that Employee 1 should not have given the insulin in the dining room, and that Resident 42 did not have a care plan or preference to receive medication and insulin in the dining room or common areas. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to ensure each resident is informed periodically of items and services not covered under Medicare for one of three residents reviewed after their Medicare stay (Resident 6). Findings Include: A review of the Skilled Nursing Facility Beneficiary Notification Review form revealed Medicare services ended for Resident 6 on February 19, 2025. A continued review of documents provided by the facility revealed that Resident 6 was not provided with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form to notify Resident 6 and/or her Representative of the cost of the facility's items and services no longer covered under Medicare. An interview with the Director of Nursing on March 11, 2025, at 1:46 PM, confirmed that the facility could not locate the SNF-ABN form and that Resident 6 should have been provided with the notice at the conclusion of her Medicare coverage. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by using proper hand hygiene techniques for one of one medication observations (South Mountain). Findings Include: Review of facility policy titled, Hand Hygiene, last reviewed and revised January 2025, revealed that staff should perform hand hygiene immediately before touching a resident, after touching a resident or the resident's immediate environment, and immediately after glove removal. Observation on March 12, 2025, at 8:00 AM, revealed Employee 1 (Licensed Practical Nurse) preparing Resident 42's medications. The medications included oral medications and injectable medication. Employee 1 then administered the medications to Resident 42 by feeding Resident 42 the oral tablets on a spoon, then applying gloves, cleaning Resident 42's abdomen with an alcohol pad, and injecting Resident 42's medication into Resident 42's abdomen. Employee 1 then returned to her medication cart and prepared oral medication, injectable medication, and topical medication for Resident 7. Employee 1 then went to Resident 7's room and fed Resident 7 the oral medications with a spoon. Employee 1 then applied gloves, cleaned Resident 7's abdomen with an alcohol pad, and injected Resident 7's injectable medication into Resident 7's abdomen. Employee 1 then applied Resident 7's topical pain relief gel to Resident 7's left shoulder using the same gloves that she was wearing to inject Resident 7's injectable medicine. Employee 1 then proceeded to her medication cart and moved it down the hall to Resident 18's room. Employee one then prepared Resident 18's medication for administration. These medications included oral medications, injectable medication, topical medication patches, and eye drops. Employee 1 then entered Resident 18's room and provided Resident 18 her oral medications on a spoon. Employee 1 then applied gloves and administered Resident 18's eye drops. Employee 1 then removed her gloves and applied a new pair. Then Employee 1 applied a pain relief patch to the back of Resident 18's neck. She then applied a pain relief patch to Resident 18's lower back. Employee 1 then removed her gloves and applied new gloves, cleaned Resident 18's abdomen with an alcohol pad, and administered Resident 18's injectable medication in Resident 18's abdomen. Employee 1 then returned to her medication cart. At no time during the medication administration observation did Employee 1 perform hand washing or use hand sanitizer. An interview with Employee 1 at the end of the medication administration observation revealed that Employee 1's medication cart was stocked with hand sanitizing gel. An interview of the Nursing Home Administrator on March 13, 2025, at 11:15 AM, revealed that Employee 1 should have washed her hands or used hand sanitizer, as appropriate, and staff reeducation had already begun. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions in the main facility kitchen. Findings include: Review of the facility policy titled, Uniform Dress Code, last revised January 2025, stated, Restrain all facial hair with beard net/restraint. Observation on March 10, 2025, at 10:54 AM revealed Employees 3 and 4 (Dietary Aides) working in and around the kitchen with uncovered beards. During an immediate interview with Employee 2 (Director of Dining Services) he stated that he would review the policy. During an interview with the Nursing Home Administrator on March 12, 2025, at 1:46 PM he agreed that Employees 3 and 4 should have been wearing beard nets. He also revealed that Employee 2 had rectified the situation. 28 Pa. Code 211.6(f) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the assessment accurately reflects the resident's status for one of 21 residents reviewed (Resident 17). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and muscle weakness. Review of Resident 17's physician orders revealed an order dated April 14, 2023, that read Admit to . hospice services . Hospice services are defined as a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Continued review of Resident 17's clinical record revealed the Resident to be admitted to hospice services on the physician's order date of April 14, 2023. Review of Resident 17's Significant Change Minimum Data Set (MDS- a tool used to assess all care areas specific to the resident), with an Assessment Reference Date of April 22, 2023, under Section O Special Treatments, Procedures and Programs revealed staff had not marked sub-section k Hospice care for the Resident within the past 14 days. An interview with the Nursing Home Administrator on June 28, 2023, at 2:33 PM, confirmed Resident 17's MDS was incorrectly coded, and staff have submitted a modification to the assessment to capture the hospice services being provided at the time of the assessment. 28 Pa. Code 211.5 (f) Clinical records

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to provide timely eating assistance for residents dependent on staff for this activity of daily living for one of 21 residents reviewed (Resident 23). Findings include: Review of Resident 23's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Observation on June 26, 2023, at 11:57 AM, revealed that Resident 23 had been served her meal in the dining area. At that time, it was observed that Employee 7 (Nurse Aide) cued Resident 23 to start eating, fed her two bites of food, then left to assist other residents. It was observed that from 11:57 AM to 12:38 PM Resident 23 sat in front of her plate, but was not able to successfully feed herself. During this time it was observed that the Resident did attempt to eat using her spoon, but was not able to get any food to her mouth. It was also observed at one point that she attempted to eat, she spilled food with her hands. At 12:38 PM, it was observed that Resident 23 was assisted by staff with eating her meal. During an interview with Employee 6 (Licensed Practical Nurse) on June 28, 2023, at 1:06 PM, she revealed that Resident 23 was on hospice (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness), her ability to feed herself varied, and that Resident 23 did need assistance with eating. Review of Resident 23's current care guide revealed that staff are to assist her with meals. Review of Resident 23's current care plan revealed that she required increased assistance with meals. During an interview with the Nursing Home Administrator on June 28, 2023, at 1:17 PM, she revealed that she spoke with nursing staff and confirmed that Resident 23 needed assistance with eating. She also revealed the expectation that Resident 23 should have received timely assistance with eating. 28 Pa. Code 211.12(b)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's nutritional interventions and care plan for one of 21 residents reviewed (Resident 27). Findings include: Review of facility policy, titled The Brethren Home Community Supplements and Bulk Nourishments Policy and Procedure revealed, Nourishments and supplements are delivered every day to each unit. Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 27's care plan on June 26, 2023, revealed cheese cubes at lunch, fortified chocolate milk with breakfast, lunch and dinner. Review of Resident 27's clinical record revealed a nutrition note dated May 10, 2023, with a nutrition diagnosis of increased nutrient needs for wound healing, and intervention of fortified chocolate milk three times per day. Review of Resident 27's clinical record revealed a nutrition note from June 20, 2023, that stated change cheese cubes from breakfast to lunch. Observation of Resident 27 during lunch meal in the dining room on unit on June 26, 2023, at 12:28 PM, revealed cheese cubes and fortified chocolate milk were not provided. Review of Resident 27's lunch meal ticket on June 27, 2023, revealed fortified chocolate milk at meals and 3-4 cheese cubes. Observation in Resident 27's room on June 27, 2023, at 9:05 AM, revealed the Resident eating the breakfast meal, and fortified chocolate milk was not provided. Observation in the dining room on unit on June 27, 2023, at 12:06 PM, revealed Resident 27 at the lunch meal, and cheese cubes were not provided. Interview with Employee 3 on June 27, 2023, at 1:51 PM, revealed cheese cubes were not brought to the unit that day or provided to Resident 27 because he believed the facility was out of cheese cubes. Interview with the Food Service Director (FSD) on June 28, 2023, at 9:26 AM, revealed cheese cubes could be obtained from personal care and will be available for Resident 27 at lunch meal. FSD further revealed he would expect nourishment items on tray tickets to be provided when available or substituted when not available. Interview with Employee 2 (Dietitian) on June 28, 2023, at 11:42 AM, revealed she would expect nutritional interventions put in place for wound healing to be provided and the care plan to be followed. Observation in the dining room on June 28, 2023, at 12:09 PM, revealed Resident 27 had completed his lunch meal, and fortified chocolate milk and cheese cubes were not provided. Interview with Employee 4 on June 28, 2023, at 12:11 PM, revealed Resident 27 was not provided cheese cubes and that she would go get them. Employee 4 further revealed Resident 27 preferred to only have soda as the lunch beverage and that she would communicate that information to the dietitian. Interview with Nursing Home Administrator on June 28, 2023, at 10:44 AM, revealed she would expect nutritional interventions put in place for wound healing to be provided and the care plan to be followed. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for one of 21 residents reviewed (Resident 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 27's physician orders included: a lipped plate (a plate with a curved, heightened edge that makes it easier to put food on utensils for those with self-feeding difficulties) for all meals, with a revision date of December 22, 2022; bent weighted utensils (heavy, curved utensils to make it easier for those with self-feeding difficulties, such as tremors related to Parkinson's disease) at meals, with a revision date of July 21, 2022; and mug with twist on lid and straw, with a revision date of May 13, 2023. Review of Resident 27's care plan on June 26, 2023, included a focus area: at risk for impaired nutrition related to diagnoses of Parkinson's disease and dementia. Interventions included adaptive equipment as ordered, with a revision date of September 30, 2020. Review of Resident 27's tray tickets revealed: Adaptive Equipment: Lip plate, right hand weighted utensils, cup with twist on lid and straw, assist as needed. Observation of Resident 27 during the lunch meal in the dining room on June 26, 2023, at 12:01 PM, revealed regular silverware was provided, and the Resident began to attempt to feed himself. Further observation on June 26, 2023, at 12:05 PM, revealed the Resident's regular fork was replaced with one weighted fork that was not bent. Observation on June 26, 2023, at 12:09 PM, revealed Resident 27 with difficulty feeding himself with the regular weighted fork. The surveyor observed the food on the fork fell to the ground when brought to the Resident's mouth. Further observation on June 26, 2023, at 12:14 PM, revealed two additional bites of food were attempted to be brought to mouth and were dropped on Resident 27's lap. No feeding assistance was provided throughout duration of the lunch meal. Resident completed his meal at 12:28 PM, with a total of five observations of unsuccessful bites of food that fell to the floor. Observation on June 27, 2023, at 9:05 AM, revealed Resident 27 was in his room, eating his breakfast meal off a regular plate with regular silverware and had a regular cup without a lid. Further observation on July 27, 2023, at 9:15 AM, revealed three bites of food fell from the regular fork to the floor. No feeding assistance was provided throughout duration of the meal. Interview with the Food Service Director on June 28, 2023, at 9:26 AM, revealed he would expect adaptive equipment to be provided, as ordered, at all meals. During an interview with the Nursing Home Administrator (NHA) on June 28, 2023, at 10:44 AM, surveyor revealed the concern with Resident 27 not receiving a lipped plate at one observed meal, receiving a regular cup without a lid at one meal, and improper utensils at two meals. NHA revealed she would expect adaptive equipment to be provided, as ordered, at all meals. 28 Pa code 211.6(b)(d) - Dietary Services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on policy review, observations, manufacturer packaging, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and four of four pantries. Findings include: Review of facility policy, titled Cross Keys Village- The Brethren Home Food Storage Policy and Procedures last revised August 22, 2022, revealed Any prepared foods, leftovers, or open containers must be stored in refrigeration at a temperature under 41 degrees Fahrenheit, be labeled and dated and must be discarded after 3 days. Observation in the main kitchen walk-in freezer on June 26, 2023 at 10:14 AM, revealed: one bag of frozen corn with a use by date of June 24, 2023; and one open bag of sweet potato fries without a label or date. Further observation in the main kitchen walk-in refrigerator revealed one open container of Dijon mustard and labeled with a use by date of June 24, 2023. Observation during initial tour of the Somerset pantry area on June 26, 2023, at 10:35 AM, revealed: one container of Cheerios cereal with a use by date of June 23, 2023; one container of sherbet frozen dessert without a date; one bag of hamburger buns with a use by date of June 24, 2023; one package of wheat dinner rolls with a use by date of June 24, 2023; two bags of unknown snacks revealed to be potato chips without a label or date; and one container of brown sugar with a spoon stored inside. Interview with Employee 5 on June 26, 2023, at 10:37 AM, revealed a spoon should not be stored inside the brown sugar container. Observation during initial tour of the Sun Valley pantry area on June 26, 2023, at 10:46 AM, revealed: three containers of sherbet frozen dessert without a date; one open container of prune juice, half full and not dated; one container of fruit cocktail with a use by date of June 25, 2023; one bag of dinner rolls labeled use by June 25, 2023; one open bag of dinner rolls without a date; and one container of brown sugar with a spoon stored inside. Observation during initial tour of the East Valley pantry area on June 26, 2023, at 10:55 AM, revealed: five containers of sherbet frozen dessert without a date; one open container of prune juice with a use by date of June 16, 2023; one open container of chocolate milk with a use by date of June 25, 2023; one container of English muffins not labeled or dated; and one bag of unknown snacks revealed to be potato chips without a label or date. Observation during initial tour of the South Mountain pantry area on June 26, 2023, at 11:04 AM, revealed: two boxes of [NAME] Krispies cereal without a date; and one open container of honey thickened lemon water dated use by July 26, 2023. Further observation of the honey thickened lemon water revealed no open date, and directions on the package revealed discard after open for 7 days. Interview with the Food Service Director on June 28, 2023, at 9:26 AM, revealed that items should be labeled and dated per policy and discarded once expired; and food items are stored in accordance with professional standards. Interview with the Nursing Home Administrator on June 28, 2023, at 10:44 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services