Based on clinical record review and staff interview, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for one of 21 residents reviewed (Resident 76). Findings include: Review of Resident 76's clinical record revealed diagnoses that included congestive heart failure (CHF- a condition characterized by a gradual loss of kidney function), atrial fibrillation (irregular heart rhythm), and hyperlipidemia (high blood cholesterol). Review of Resident 76's physician orders revealed an order for Daily weights. Notify doctor and give PRN (as needed) Lasix (diuretic- a medication that increases urine production and excretion of water) if weight gain > or = 2 lbs (pounds) in 1 day or 5lbs in a week, in the morning related to CHF, with a start date of September 22, 2023. Further review of Resident 76's physician orders revealed an order for Lasix Oral Tablet 40 MG, Give 0.5 tablet by mouth every 24 hours as needed for Weight gain, give for weight gain of 2 pounds in 1 day or 5 pounds in 1 week. Give half a tab to equal 20 mg, with a start date of May 16, 2024. Review of Resident 76's care plan revealed a focus area [Resident 76] has cardiac disease, with an intervention for obtain weights as indicated and report significant changes, initiated May 1, 2023. Review of Resident 76's clinical record revealed she had a weight gain of 2.8 lbs from August 28 to 29, 2024. Further review of her clinical record failed to reveal doctor notification, and review of her August MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) failed to reveal the PRN Lasix order was administered. Review of Resident 76's clinical record revealed she had a weight gain of 4.6 lbs from November 2 to 3, 2024; further review of her clinical record failed to reveal doctor notification, and review of her November MAR failed to reveal the PRN Lasix order was administered. Interview with the Director of Nursing on May 15, 2025, at 10:37 AM, revealed the doctor was not notified of the weight gain on the aforementioned dates and the PRN Lasix was not given. She further revealed her expectation of doctor notification and PRN Lasix administration per physician order. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility document review and staff interview, it was determined that the facility's Quality Assurance Committee failed to meet on a quarterly basis for one quarter of four reviewed (first quarter of 2025). Findings include: Review of the facility's Quality Assurance Committee meeting signatory pages revealed that the facility's Quality Assurance Committee did not meet during the first quarter of year 2025 (January, February, and March). During a staff interview on May 15, 2025, at approximately 10:20 AM, Nursing Home Administrator confirmed that it was the facility's expectation that the Quality Assurance Committee meets at least once every quarter. 28 Pa code 201.18(b)(3) Management

Based on facility policy review, observations, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas. Findings include: Review of facility policy, titled Food Storage last reviewed April 4, 2025, read, in part, Food will be purchased in quantities that can be stored properly and arranged in food groups for organized storage and inventory. All stock must be rotated with each new order received. Food should be dated as it is placed on the shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. Scoops should be kept covered in a protected area near the containers rather than in the containers. Thermometers should be checked at least two times each day. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. All foods should be covered, labeled and dated routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. Observation in the main kitchen on May 12, 2025, at 9:25 AM, revealed one bin of brown sugar not labeled or dated, and one bin of white sugar dated 9-19. Interview with Employee 1 (Dietary Manager) on May 12, 2025, at 9:27 AM, revealed the brown sugar should be labeled and dated, and the white sugar had been replenished since September 19, 2024. Observation in walk-in freezer unit on May 12, 2025, at 9:30 AM, revealed four packs of succotash vegetables not dated, and one appeared to be freezer burned; and one box of green beans with the packaging unwrapped and left open to air. Observation in the dry storage area on May 12, 2025, at 9:41 AM, revealed three packages of hot dog buns with a best by date of May 3, 2025; one package of hot dog buns with a best by date of May 7, 2025; three boxes of fudge round cookies not dated; seven boxes of oatmeal cookies not dated; six bags of devil's food cake mix not dated; and seven bags of fudge brownie mix not dated. Observation in the 2nd Floor pantry area on May 12, 2025, at 9:49 AM, revealed refrigerator and freezer temperatures were missing from the May 2025 temperature log on May 2-5, 10, and 11, 2025. Further observation in the 2nd Floor pantry area on May 12, 2025, at 9:50 AM, revealed one bag of Texas toast not dated; and a bin of individual snacks containing oatmeal cookies, fudge round cookies, and fig cookies not dated. Observation in the 2nd Floor pantry area refrigerator on May 12, 2025, at 9:51 AM, revealed two cartons of fat free milk with a sell by date of May 9, 2025. Observation in the 3rd Floor pantry area on May 12, 2025, at 9:56 AM, revealed refrigerator and freezer temperatures were missing from the temperature log on May 2-11, 2025. Further observation in the 3rd Floor pantry area on May 12, 2025, at 9:57 AM, revealed half of a loaf of Texas toast not dated; three containers of corn flake cereal not dated; and a bin of individual snacks containing oatmeal cookies, fudge round cookies, and fig cookies not dated. Observation in the 3rd Floor pantry area refrigerator on May 12, 2025, at 9:58 AM, revealed a container of two open vanilla puddings in the refrigerator labeled medication pass. Interview with Employee 1 on May 12, 2025, at 9:59 AM, revealed she has had numerous conversations with nursing staff that they are not to leave open puddings in the refrigerator that are left over from medication pass. Follow-up visit in the 3rd Floor nourishment area on May 13, 2025, at 12:37 PM, revealed refrigerator and freezer temperatures failed to be logged on May 12, 2025, in AM and PM. Follow-up visit in the 2nd Floor nourishment area on May 13, 2025, at 12:44 PM, revealed refrigerator and freezer temperatures failed to be logged on May 12, 2025, in AM and PM; and revealed one container of thickening powder labeled with two different open dates of May 9, 2025, and May 12, 2025, that was open with a scoop stored inside. Review of select facility temperature logs provided revealed the facility was unable to provide kitchen equipment temperature logs for the dish machine, reach in three-door refrigerator, kitchen walk-in refrigerator and freezer, or 2nd and 3rd floor nourishment areas from November 2024, December 2024, and January 2025. Review of the February 2025 2nd Floor pantry area nourishment room temperature log, revealed refrigerator temperatures failed to be recorded on February 21-27 in AM, and February 15-28 in PM; and revealed freezer temperatures failed to be recorded on February 15-28, 2025, in AM and PM. Review of the February 2025 3rd Floor pantry area nourishment room temperature log, revealed refrigerator and freezer temperatures failed to be recorded on February 9-28, 2025, in AM and PM. Review of the April 2025 2nd Floor pantry area nourishment room temperature log, revealed refrigerator and freezer temperatures failed to be recorded on April 17-23, 25, and 27-30 in AM; refrigerator temperatures failed to be recorded on April 20-23, 25, and 27-30 in PM; and freezer temperatures failed to be recorded on April 23, 25, and 27-30 in PM. Interview with the Nursing Home Administrator on May 14, 2025, at 10:17 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 and kitchen equipment are stored, monitored, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.12(d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 26 residents reviewed (Resident 9 and 26). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included obstructive sleep apnea (characterized by episodes of a complete [apnea] or partial collapse [hypopnea] of the upper airway with an associated decrease in oxygen saturation or arousal from sleep) and seizures (a burst of uncontrolled electrical activity between brain cells). Review of Resident 9's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated April 4, 2024, revealed in Section O0110. Special Treatments, Procedures, and Programs, G1. Non-invasive Mechanical Ventilator, that Resident 9 did not use a non-invasive mechanical ventilator during the previous 14 days. Review of Resident 9's Treatment Administration Record (TAR) for the month of April 2024, revealed that Resident 9 used a CPAP machine (continuous positive airway pressure machine - is a machine that uses mild air pressure to keep breathing airways open while you sleep) from April 1-4, 2024. Interview with the Director of Nursing (DON) on June 13, 2024, at 9:35 AM, revealed that the MDS completed on April 4, 2024, should have been coded to reveal that Resident 9 used a CPAP machine. Review of Resident 26's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a persistent feeling of worry, nervousness, or unease), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and fibromyalgia (a disorder that causes widespread pain, fatigue, sleep problems, and cognitive difficulties). During an interview with Resident 26 on June 10, 2024, at 11:46 AM, revealed she has pain in her abdomen and medicine is not always effective in managing her pain. Review of Resident 26's clinical record revealed a nursing progress note written on June 5, 2024, that stated she had been more focused on having abdominal discomfort and believes she has colon cancer. Review of Resident 26's routine physician notes and clinical record failed to reveal notation that the Resident has any type of active cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. During an interview with the DON on June 13, 2024, at 9:17 AM, she revealed Resident 26 has been followed by the physician and gynecology for fibroids (a non-cancerous tumor in the uterus) that contribute to her abdominal pain, and that she has no record of having an active cancer diagnosis. Follow-up interview with the DON on June 13, 2024, at 11:25 AM, revealed she would expect the residents' MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 8). Findings include: Based on facility policy, titled Care Plan Policy, not dated, read, in part, Changes in the resident's condition must be reported to the MDS Assessment Coordinator (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) so that a review of the resident assessment and care plan should be made. Review of Resident 8's clinical record revealed diagnoses that included difficulty in walking and muscle weakness. Review of Resident 8's clinical record on June 11, 2024, at 9:28 AM, revealed she was discharged to the hospital on May 1, 2024, and returned to the facility on May 2, 2024. Observation of Resident 8 on June 11, 2024, at 09:49 AM, revealed her face was heavily bruised. Interview with Resident 8 on June 11, 2024, at 09:52 AM, revealed she had a fall after an appointment and went directly to the hospital on May 1, 2024. Review of Resident 8's clinical record revealed she had an MDS assessment completed after her return from the hospital on May 15, 2024. Review of Resident 8's care plan on June 11, 2024, at 1:57 PM, revealed a focus area: [Resident 8] is at risk for falls due to deconditions (decline in physical fitness), last revised April 24, 2024, with a goal Minimize [Resident 8's] risk for injury related to falls through the next review last revised March 21, 2024. Interview with the Director of Nursing on June 13, 2024, at 10:25 AM, revealed she would expect Resident 8's fall care plan to be revised that she has had a fall with injury. 28 Pa. Code 211.12(d)(3)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 23 residents reviewed (Resident 100). Findings include: Review of Resident 100's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and presence of cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). Observation of Resident 100 on June 10, 2024, at 10:19 AM, revealed a pacemaker monitoring device (a device used by a cardiologist [heart specialist] to perform an electronic periodic pacemaker function test) that was noted to be plugged into the electrical outlet and turned on. Review of Resident 100's physician orders on June 11, 2024, at 12:08 PM, failed to reveal any orders regarding their pacemaker monitoring or follow-up cardiology appointments. Review of Resident 100's care plan on June 11, 2024, at 12:15 PM, revealed a care plan focus for cardiac disease related to hypertension, initiated on April 5, 2024, which included an intervention for pacemaker checks as ordered, but failed to include any safety interventions associated with the presence of the pacemaker or cardiology follow-up visits. Review of Resident 100's hospital discharge paperwork dated April 5, 2024, revealed that the Resident had a cardiology follow-up appointment on Thursday, September 12, 2024, at 1:30 PM. During an interview with the Nursing Home Administrator, Director of Nursing (DON), and Assistant Director of Nursing on June 12, 2024, at 11:10 AM, the DON indicated that Resident 100 had not had any pacemaker checks since admission as none were due to be completed. The DON further indicated that when Resident 100 returned from an appointment at the wound clinic on June 11, 2024, all their cardiac appointments including pacemaker checks were listed on the after-visit summary and nursing staff added them to Resident 100's orders. The DON confirmed that the facility knew that Resident 100 had a pacemaker at their admission on [DATE], and that nursing staff should have obtained all necessary information from Resident 100's cardiologist regarding pacemaker checks and follow-up appointments. The DON also confirmed all safety measures associated with the presence of a pacemaker should have been implemented at the time of Resident 100's admission and that their care plan has now been revised. During a follow-up interview with the DON on June 13, 2024, at 10:15 AM, the DON indicated that she had researched Resident 100's pacemaker checks a little further that morning. The DON said that Resident 100 was to have an electronic remote check on April 18, 2024, however, the POA had canceled it because the pacemaker monitoring device was still at Resident 100's prior assisted living facility. The DON provided a copy of an after-visit summary dated June 12, 2024, that indicated that a remote electronic pacemaker check was completed on June 12, 2024. The DON also indicated that the cardiologist's office said that if there were to be a problem with Resident 100's pacemaker, an alert would be sent to the cardiologist's office who would then contact the facility. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and Resident Responsible Party and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents reviewed (Resident 91). Findings include: Review of facility policy, titled Policy and Procedure Trauma Informed Care, last revised April 15, 2024, read, in part: Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD [Post Traumatic Stress Disorder] will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Procedure . 7. When a Resident has experienced a traumatic event, The Social worker will interview the resident/resident representative regarding potential/actual triggers that may cause re-traumatization. Experiences, preferences, and/or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident. 8. The IDT team will ensure that an individualized resident centered care plan is developed for resident that has experienced a traumatic event. The care plan will include but is not limited to the following: Identification of the stressor/past life trauma. Identification of interventions that mitigate against re-traumatization. Identify triggers that could cause re-traumatization. Review of Resident 91's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and severe recurrent major depressive disorder with psychotic symptoms (a serious mental health condition that combines a depressed mood with psychosis [a disconnection from reality] that can manifest as hallucinations or delusions). During an interview on June 10, 2024, at 1:24 PM, with Resident 91's Responsible Party, it was revealed that Resident 91 suffered from PTSD from fighting in the Vietnam War and being exposed to harmful chemicals. Review of Resident 91's clinical record revealed a social services assessment dated [DATE]. The assessment indicated Resident 91's PTSD was related to fighting in a war and witnessing various acts of violence, being a prisoner of war, and being exposed to harmful chemicals while in the war. The assessor indicated active signs or symptoms of trauma and interventions were needed. Review of Resident 91's comprehensive plan of care revealed a focus area for risk for changes in mood related to dementia, depression, PTSD and is at risk for adverse effects related to use of antipsychotic and depression medication use, but failed to indicate the source of Resident 91's PTSD or any known triggers or interventions. Further review of Resident 91's clinical record failed to reveal evidence that the facility identified or attempted to identify Resident 91's PTSD triggers. During a staff interview with Employee 2 (Social Services Director), on June 12, 2024, at 2:00 PM, it was revealed that she had no further information to provide and that the previous social services director had completed Resident 91's screening. During a staff interview on June 13, 2024 at 10:14 AM, with Employee 1 (Assistant Director of Nursing), in the presence of the Director of Nursing, it was revealed that the facility was unable to provide any further evidence that culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident had been provided. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for one of 26 residents reviewed (Resident 77). Findings include: Review of Resident 77's clinical record on August 14, 2023, revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension (high blood pressure). Observation in Resident 77's room on August 14, 2023, at 12:52 PM, revealed there was no call bell plugged into the wall or in reach. Interview with Employee 14 on August 14, 2023, at 12:52 PM, revealed she was unable to locate a call bell for Resident 77 in his room. Employee 14 stated she was unsure why he did not have a call bell, she left the room, and returned with a metal call bell to place at the Resident's bedside. Review of Resident 77's care plan on August 14, 2023, revealed a focus area: [Resident 77] is at risk for falls due to weakness with an intervention for call bell in reach, initiated October 17, 2022. Interview with the Director of Nursing on August 16, 2023, at 1:58 PM, revealed she would expect Resident 77's call bell to be in reach. 28 Pa code 201.29(d) - Resident Rights 28 Pa Code 211.12(d)(1) Nursing Services

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident's care plan was updated/revised to reflect the resident's specific care needs for three of 26 residents reviewed (Resident 36, 39, and 71). Findings include: Review of Resident 36's clinical record revealed diagnoses that included morbid obesity (obesity in which the person weighs 80-100 pounds over their ideal body weight) and protein-calorie malnutrition (nutritional status in reduced availability of nutrients leads to changes in body composition and function). Review of Resident 36's progress note dated July 20, 2023, by Employee 3 (Clinical Dietary Director) indicated Resident 36 had a significant weigh loss of 13 pounds (5.1%) over the past month and that this weight loss was beneficial. Review of Resident 36's care plan revealed a care plan focus for nutritional risk, dated May 31, 2023. The care plan revealed no revisions indicating the significant weight loss experienced by Resident 36 as stated above. It was noted that one of the care plan goals indicated it would be beneficial for [Resident 36] to gradually lose weight through next review date, with a revision date of June 1, 2023. Email communication was sent to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 16, 2023, at 9:34 PM, to inform them of the care plan concern and additional information was requested. During an interview on August 17, 2023, at 11:40 AM, with the NHA and DON, the DON indicated that she had spoken to Employee 3 and that Employee 3 indicated that they had not care planned the significant weight losses and that they were updating the care plan. The DON confirmed that she would expect the care plan to have been updated if the Resident had a significant weight loss. During an interview with Employee 3 on August 17, 2023, at 1:30 PM, Employee 3 indicated that they had updated the care plan for the significant weight loss, and that they had not done so prior since it was documented on Resident 39's care plan that weight loss would be beneficial. Employee 3 did confirm that Resident 39 had experienced a significant weight loss. Review of Resident 39's clinical record revealed diagnoses that included obesity (disorder involving excessive body fat that increases the risk of health problems) and chronic obstructive pulmonary disorder (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 39's progress notes revealed the following notes: 1) note dated April 28, 2023, by Employee 3 that indicated Resident 39 had experienced a significant weight loss of 18.8 pounds (11.7%) in one month and a significant weight loss of 22 pounds (13.4%) over the past six months; 2) note dated May 30, 2023, by Employee 3 that indicated Resident 39's weight had been stable over the past month, but had a significant weight loss of 21.5 pounds (13.1%) over the past six months; 3) note dated June 14, 2023, by Employee 3 that indicated Resident 39 had experienced a two pound gain over the past month, and that had experienced a 18.1 pound beneficial weight loss; 4) noted dated July 15, 2023, by Employee 3 that indicated Resident 39 had lost 16.6 pounds (10.3%) between March 9, 2023, and April 9, 2023, and that their weight had been stable since April 9, 2023; and 5) note dated August 10, 2023, by Employee 3 that indicated Resident 39 was exhibiting a significant weight loss of 8.6 pounds over the past month, a significant weight loss of 25.6 pounds over the past 6 months, and a 7 pound weight loss since July 18, 2023. Review of Resident 39's care plan revealed a focus for nutritional risk, dated September 22, 2021. Care plan review revealed no revisions indicating the significant weight losses experienced by Resident 39 as stated above. It was noted that one of the care plan goals indicated it would be beneficial for [Resident 39] to gradually lose weight through next review date, with a revision date of July 31, 2023. Email communication was sent to the NHA and DON on August 16, 2023, at 9:34 PM, to inform them of the care plan concern and additional information was requested. During an interview on August 17, 2023, at 11:40 AM, with the NHA and DON, the DON indicated that she had spoken to Employee 3 and that Employee 3 indicated that they had not care planned the significant weight losses, and that they were updating the care plan. The DON confirmed that she would expect the care plan to have been updated if the resident had a significant weight loss. During an interview with Employee 3 on August 17, 2023, at 1:30 PM, Employee 3 indicated that they had updated the care plan for the significant weight loss, and that they had not done so prior since it was documented on Resident 39's care plan that weight loss would be beneficial. Employee 3 did confirm that Resident 39 had experienced significant weight losses. Review of Resident 71's clinical record on August 15, 2023, revealed diagnoses that included dry eye syndrome, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 71's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of June 22, 2023, revealed Section G: Activities of Daily Living (ADL) Assistance, subsection, H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g. Tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration), Resident 71 was coded as requiring extensive assistance with one-person physical assist, which was a decline in ability from her April MDS assessment. Review of Resident 71's care plan revealed a focus area of [Resident 71] has an ADL (Activities of Daily Living) self-care performance deficit related to decreased strength and endurance, dementia, pain, impaired mobility, and anxiety, with an intervention stating [Resident 71] is able to feed self after set up, last revised April 8, 2022. Interview with DON on August 17, 2023, at 1:46 PM, revealed she would expect the care plan to be updated to reflect resident 71's eating decline and care needs. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of two residents reviewed for use of a catheter (Resident 61). Findings Include: Review of Resident 61's clinical record revealed diagnoses that included malignant neoplasm of prostate (prostate cancer) and obstructive and reflux uropathy (blockage of tubes that carry urine that can cause swelling or damage to the kidneys). Review of Resident 61's physician orders revealed an order dated July 6, 2022, for a foley catheter for neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves) and obstructive and reflux uropathy. Review of Resident 61's current [NAME] (resident daily care guide) revealed that catheter care was to be done every shift and as needed. Review of task documentation for the period of July 18, 2023, through August 16, 2023, revealed that it was not documented that Resident 61 received catheter care on each shift on the following dates: July 18, 19, 24, 29, and 31, and August 8 and 15, 2023. No refusals were documented. During an interview with the Director of Nursing on August 17, 2023, at 11:53 AM, she revealed that the facility policy does not address frequency of catheter care, but the standard of care would be for catheter care to be provided each shift (three times per day). 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 29 opportunities. Findings include: Observation of medication administration on August 16, 2023, at 9:11 AM, revealed Employee 5 (Licensed Practical Nurse) administering magnesium oxide 400 milligrams to Resident 173. Review of Resident 173's current physician orders revealed the following order: Magnesium 250 milligrams give one tablet by mouth in the morning related to disorders of magnesium metabolism, dated August 15, 2023. During an interview with Employee 5 on August 16, 2023, at 10:47 AM, Employee 5 verified the order and confirmed that she should have given the 250 milligrams instead of 400 milligrams. Observation of medication administration on August 16, 2023, at 9:11 AM, revealed Employee 5 administering Cymbalta 20 milligrams, one capsule, to Resident 98. Review of Resident 98's current physician orders revealed the following order: Cymbalta oral capsule give 80 milligrams by mouth in the morning related to major depressive disorder, dated May 26, 2023. During an interview with Employee 5 on August 16, 2023, at 10:47 AM, the medication blister packaging was reviewed again and it was noted on the medication identification label that four capsules were to be administered. Employee 5 verified the order and confirmed that they only gave one capsule. They also indicated that they would give the three additional capsules. During medication administration observation there were two errors and 29 opportunities\, resulting in a medication error rate of 6.9%. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 16, 2023, at 1:33 PM, they were made aware of the medication errors observed and Employee 5's interview. During a follow-up interview with the NHA and DON on August 17, 2023, at 11:43 AM, the DON confirmed that she would expect medications to be administered per physician orders. 28 Pa. Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined the facility failed to maintain a safe, clean, and home-like environment for 2 of 63 residents reviewed (Residents 12 and 54) and in two of two dining rooms. Findings Include: Review of facility policy, titled Meal Service and Distribution revealed, A comfortable, attractive atmosphere will be maintained in the dining room area .suggestions for a pleasant environment include use of clean, wrinkle-free tablecloths, centerpieces, background music, and placemats. Observation of the second floor dining area on August 14, 2023, at 11:49 AM, revealed 17 residents were eating meals served on trays. Further observation in the second floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. Interview with Employee 2 in second floor dining area on August 14, 2023, at 11:51 AM, revealed residents have been eating on trays in the dining room since COVID. Observation of the third floor dining area on August 14, 2023, at 12:17 PM, revealed 27 residents were eating meals served on trays. Further observation in the third floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. During an interview with Nursing Home Administrator (NHA) on August 16, 2023, at 2:00 PM, the surveyor revealed a concern with residents being served meals on trays and lack of a pleasant environment in the dining rooms. No further information was provided. Observation in Resident 12's room on August 15, 2023, at 9:34 AM, and on August 16, 2023, at 1:20 PM, revealed bilateral enablers were present on Resident 12's bed. Observation of the inside of the enablers bars revealed an accumulation of dried liquid, crumbs and debris. During an interview with Employee 16 (Licensed Practical Nurse) on August 15, 2023, at 9:46 AM, she acknowledged the enablers were soiled, and revealed that she was uncertain about who normally cleans them. Observation on August 17, 2023, at 10:58 AM, revealed Resident 12's enabler bars had been cleaned. During an interview with the Director of Nursing (DON) on August 17, 2023, 11:55 AM, she confirmed that the enabler bars had been cleaned, and revealed the expectation that Resident 12's enabler bars should have been clean. Observations of Resident 54's room on August 15, 2023, a 10:03 AM and 1:25 PM, and on August 16, 2023, at 9:20 AM, revealed bilateral enabler bars attached to Resident 54's bed. Observation of the left side enabler bar revealed the bar appeared dirty, with a dried, brown substance splattered on the enabler bar. Further observation revealed a pool of a dried, brown substance on the bottom of the enabler bar. On August 16, 2023, at 1:45 PM, the NHA and DON were made aware of the observations of Resident 54's enabler bar. Observation of Resident 54's enabler bars on August 17, 2023, at 10:55 AM, revealed the enablers had been cleaned. During an interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that she personally cleaned Resident 54's enabler bars and stated that enablers should be cleaned as needed. 28 Pa. Code 201.18(e)(2.1) Management

Based on personnel file review, facility policy review, job descriptions, and staff interviews, it was determined that the facility failed to implement written policies and procedures by not completing criminal background checks prior to hire for five of five personnel records reviewed (Employees 4, 5, 6, 7, and 8); and verifying professional licensure for three of three personnel records reviewed. Findings include: Review of the facility's current policy, titled Abuse Prevention & Reporting Policy revealed in the section, titled Policy Statement that the facility will comply with all Federal, State, and local regulations regarding the prevention, recognition, and reporting of abuse, neglect, and/or misappropriation of property. Review of section of the policy, titled Procedure indicated 1) Individuals functioning in an 'employee' status .will have a State Criminal Background Check completed at the time of employment; and 2) [in part] Persons hired as part of the professional staff .are required to have and maintain a valid current license or certification .and must submit a copy of their license on or before their first day of orientation. Review of the policy in its entirety did not reveal that the facility would complete a license or certification verification prior to hire. Review Employee 4's (Speech Language Pathologist) personnel file revealed that their date of hire was August 1, 2023; that their criminal background check was completed on August 2, 2023, at 11:40 AM; and that there was no licensure verification present. Review of Employee 5's (Licensed Practical Nurse) personnel file revealed that their date of hire was June 27, 2023; that their criminal background check was completed on June 29, 2023, at 8:13 AM; and that their license verification was completed June 29, 2023. Review of Employee 6's (Registered Nurse) personnel file revealed that their date of hire was April 25, 2023; that their criminal background check was completed on April 27, 2023, at 10:12 AM; and that their license verification was completed on April 25, 2023. Review of Employee 7's (Nurse Aide) personnel file revealed that their date of hire was June 6, 2023; and that their criminal background check was completed on June 14, 2023, at 3:18 PM; and that there was no certification verification present. Review of Employee 8's (Cook) personnel file revealed that their date of hire was August 1, 2023; and that their criminal background check was completed on August 2, 2023, at 11:40 AM. During an interview on August 16, 2023, at 1:38 PM, the aforementioned concerns were shared with the Nursing Home Administrator (NHA) and the Director of Nursing, at which time additional information was requested. During an interview on August 17, 2023, at 9:30 AM, with the NHA, he indicated that the facility does not complete the criminal background checks until the employee shows up for their first day of employment, secondary to cost, because there are several times when the individual does not show up for their first day. He further indicated that on day one of orientation, which would also be the date of hire, that the team member would be in the classroom setting all day and that the team members do not have resident contact until day 2. He further indicated that he would provide additional information for review. On August 17, 2023, at 11:33 AM, the NHA provided additional information for review (time card reports for Employees 4, 5, 6, 7, and 8; license verification for Employee 4, and training information for Employee 7). Review of this additional information revealed the following: Employee 4 had worked on August 1, 2023, from 8:30 AM to 2:45 PM (orientation day); August 2, 2023, from 10:15 AM to 4:00 PM; and August 3, 2023, from 8:30 AM to 2:15 PM, and that their license verification was completed on August 16, 2023, with no disciplinary actions noted; Employee 5 had worked only on June 27, 2023 (orientation day); Employee 6 had worked only on April 25, 2023 (orientation day); Employee 7 had just completed nurse aide training on July 28, 2023, has not yet completed certification testing, and he worked on June 6, 2023, from 8:30 AM to 2:45 PM; June 9, 2023, from 10:00 AM to 6:00 PM; June 12, 2023, from 10:00 AM to 6:15 PM; June 13, 2023, from 10:00 AM to 6:15 PM; and June 14, 2023, from 10:00 AM to 6:00 PM, in the role of Helping Hands (a position that provides general support to the residents as needed and performs basic housekeeping duties as assigned); and Employee 8 had worked on August 1, 2023 from 8:30 AM to 2:45 PM (orientation day), and August 2, 2023, from 5:00 AM to 2:00 PM. During an interview on August 17, 2023, at 1:20 PM with the NHA, he confirmed that the background checks and license verifications were not completed prior to hire or on the day of hire. He further indicated that he would expect background checks and license verification to be completed at time of hire. During a final follow-up interview on August 17, 2023, at 1:43 PM, NHA confirmed that he had no additional information to provide. 28 Pa. Code 201.18(e)(1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for four of 26 residents reviewed (Residents 55, 58, 71, and 110). Findings Include: Review of Resident 55's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive mental deterioration due to generalized degeneration of the brain, characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and delusional disorders (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 55's current physician orders revealed an order for Quetiapine (Seroquel) (antipsychotic medication) 25 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Review of Resident 55's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of November 22, 2022, revealed in section N Medications, that Resident 55 had not received an antipsychotic medication in the look back period. Review of Resident 55's November 2022 Medication Administration Record revealed that they had received Quetiapine (an antipsychotic medication) 25 milligrams at bedtime daily, as per the physician's order. Review of Resident 55's Modified Annual Comprehensive MDS with the assessment reference date of February 13, 2023, revealed in Section N Medications, that the physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 3, 2023. Review of physician services progress notes and pharmacy recommendations revealed that the clinical contraindication for a gradual dose reduction was dated February 2, 2023. Review of Resident 55's Quarterly MDS with the assessment reference date of May 16, 2023, revealed in Section N Medications, that they had not had any gradual dose reductions and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 23, 2023. Review of psychiatric physician services progress notes dated February 16, 2023, revealed that their Quetiapine (an antipsychotic medication) was to be reduced to 12.5 milligrams at bedtime, daily. Review of Resident's clinical record failed to reveal any physician services progress notes dated February 23, 2023. Review of Resident 55's physician orders revealed that their current order was for Quetiapine 25 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Review of Resident 55's Quarterly MDS with the assessment reference date of May 31, 2023, revealed in Section N Medications, that they were coded as not having a gradual dose reduction and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 2, 2023. As stated above, Resident 55 had a gradual dose reduction of their Quetiapine on February 17, 2023. During an interview with Employee 2 (MDS Coordinator) on August 17, 2023, at 10:39 AM, all the above coding concerns were shared. Employee 2 indicated they would follow-up on the concerns identified. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 17, 2023, at 11:43 AM, the aforementioned concerns were shared with them as well. Email communication received from Employee 2 on August 17, 2023, at 12:33 PM, indicated that corrections were completed for MDS November 11, 2022, to code the receiving of antipsychotics; February 13, 2023, to code the correct date of the clinical contraindication of a gradual dose reduction to February 2, 2023; May 16, 2023, to code the gradual dose reduction completed on February 17, 2023; and May 31, 2023, to code the gradual dose reduction completed on February 17, 2023. During an interview with the DON on August 17, 2023, at 1:04 PM, she confirmed that she would expect the MDSs to have been coded accurately. Review of Resident 58's clinical record on August 15, 2023, revealed diagnoses that included chronic conjunctivitis (chronic eye inflammation caused by an infection), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 58's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution (antibiotic eye drops) 0.3 % Instill two drops in both eyes, two times a day for chronic conjunctivitis, wait five minutes to prevent wash out, with a start date of March 15, 2023. Review of Resident 58's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify resident's physical, mental, and psychosocial needs) with ARD (assessment reference date - last day of the assessment period) of March 27, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. Review of Resident 58's Quarterly MDS with ARD of June 27, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. During a staff interview on August 17, 2023, at 1:32 PM, Employee 2 confirmed that Resident 58's MDS assessments with ARD of March 27, 2023, and June 27, 2023, should have included antibiotic medication for seven days and were coded incorrectly. Interview with DON on August 17, 2023, at 1:40 PM, revealed it was the facility's expectation that resident assessments are coded accurately. Review of Resident 71's clinical record on July 13, 2023, revealed diagnoses that included dry eye syndrome, dementia, and dysphagia. Review of Resident 71's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution 0.3 % Instill two drops in both eyes, three times a day for blepharitis (eye inflammation), for seven Days from June 16, 2023, to June 23, 2023. Further review of Resident 71's physician orders revealed no order for an anticoagulant medication between the dates of June 16, 2023, and June 22, 2023. Review of Resident 71's Quarterly MDS with ARD of June 22, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic, and was marked 7 of 7 days for receiving an anticoagulant. Email correspondence with DON on August 16, 2023, at 4:01 PM, revealed Resident 71 was on antibiotic eye drops during look-back for ARD June 22, 2023, and that Employee 2 should not have coded anticoagulant and should have coded antibiotic. Interview with DON on August 17, 2023, at 11:51 PM, revealed it was the facility's expectation that the resident assessment would be coded accurately. Review of Resident 110's clinical record revealed diagnoses that included dementia with behavioral disturbance and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Review of Resident 110's June 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order, effective June 1, 2023, for Risperdal (antipsychotic medication) at bedtime, and an order for Risperdal daily, effective June 3, 2023. Review of psychiatric service provider progress notes dated April 20, 2023, revealed that a gradual dose reduction of Resident 110's psychoactive medication (to include Risperdal) was not recommended at that time due to ongoing clinical treatment for anxiety and delusional disorder. Review of Resident 110's June 7, 2023, and June 26, 2023, quarterly MDS assessments revealed that neither assessment was coded to indicate that the practitioner had documented that a gradual dose reduction of antipsychotic medication was contraindicated. During an interview with the DON on August 17, 2023, at 11:56 AM, she deferred to the MDS coordinator. During an interview with Employee 2 on August 17, 2023, at 12:40 PM, she acknowledged that the progress note written by the psychiatric provider on April 20, 2023, could be interpreted as meeting the criteria to be coded on the MDS that the practitioner documented that an antipsychotic gradual dose reduction was contraindicated. 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided, in accordance with professional standards of practice, that would meet each resident's physical, mental, and psychosocial needs for four of 28 residents reviewed (Residents 12, 50, 54, and 63). Findings Include: Review of Resident 12's clinical record revealed diagnoses that included history of traumatic brain injury (an external mechanical force such as a violent blow to the head, which causes the brain to not function properly) and abnormal posture. Review of Resident 12's physician orders revealed an order, dated December 10, 2022, for gerisleeves (cloth sleeves worn on the arms to prevent skin irritation or injury) to bilateral arms when up in wheelchair. Review of Resident 12's current care plan revealed an intervention, dated August 23, 2022, for Resident 12 to wear gerisleeves on both arms when in her wheelchair. Observations on August 15, 2023, at 9:34 AM and at 1:34 PM, and on August 16, 2023, at 11:59 AM and at 1:20 PM, revealed Resident 12 was in her wheelchair. Resident 12 was not wearing gerisleeves. During an interview with the Director of Nursing (DON) on August 17, 2023, at 11:56 AM, she revealed the expectation that Resident 12 should have been wearing the gerisleeves. Review of Resident 50's clinical record revealed diagnoses that included pressure ulcer of right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), osteomyelitis (infection of the bone), and diabetes mellitus (DM - a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 50's physician orders revealed an order for Strict pressure relief to BLE [bilateral lower extremities]. Bilateral multipodus boots when in bed every shift related to nonpressure chronic ulcer of unspecified heel and midfoot with unspecified severity, with a start date of May 18, 2023. Review of Resident 50's care plan revealed a focus area: [Resident 50] is at risk for skin breakdown related to impaired mobility, DM, incontinence, pressure ulcers, noted osteomyelitis to right ankle with actual skin breakdown, initiated May 15, 2023, and last revised on August 4, 2023, with an intervention for Bi-lateral multipodus boots while in bed, initiated May 16, 2023. Observation of Resident 50 in his room on August 15, 2023, at 1:15 PM, revealed the Resident was laying in bed and his multipodus boots were sitting in his wheelchair, beside his bed. Interview with Resident 50 on August 15, 2023, at 1:17 PM, revealed he does not refuse to wear his boots, but, depending on which nurse aide is working, they sometimes take them off before he gets into bed. Interview with the DON on August 17, 2023, at 11:51 AM, revealed she would expect Resident 50 to be wearing his multipodus boots in bed per physician order and per his care plan. Review of Resident 54's clinical record revealed diagnoses that included hypertension (elevated blood pressure), Type 2 Diabetes Mellitus, and end stage renal disease (ESRD- when the kidneys no longer work as they should to meet the body's needs). Review of Resident 54's physician orders revealed an order dated July 17, 2023, for hipsters at all times (impact-absorbing pads over the critical hip fracture area minimize potential damage that can occur from a fall). Review of Resident 54's current care plan revealed an intervention dated July 17, 2023, for hipsters at all times, may remove for care. Observation of Resident 54 on August 14, 2023, at 1:11 PM, revealed Resident 54 in his room alone, in bed, asleep, wearing only a shirt and a brief. Resident 54 was not observed to be wearing hipsters. Observation of Resident 54 on August 15, 2023, at 9:30 AM, revealed Resident 54 in his room alone, in bed, wearing only a brief. Resident 54 was not observed to be wearing hipsters. During an interview with Employee 5 (Licensed Practical Nurse) on August 16, 2023, at 10:13 AM, Employee 5 stated that she is unsure why Resident 54 was not wearing his hipsters on August 14 or 15, 2023. She stated they may have been soiled, as some of the hipsters were being laundered. On August 16, 2023, at 1:45 PM, the Nursing Home Administrator (NHA) and DON were made aware of Resident 54 not wearing his hipsters on the aforementioned dates and times. In a follow-up interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that Resident 54's hipsters got soiled during an incontinence episode, and they were being laundered. When asked if the facility had extra hipsters to be provided during a situation like that, she stated the facility does have extra hipsters, but they were all used up. No additional information was provided. Review of Resident 63's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients needed for health), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 63's care plan revealed a focus area: nutritional risk related to mechanical diet, reflux, dementia, hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), depression, chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertension (high blood pressure), last revised May 19, 2023, with an intervention for provide a water pitcher at bedside to promote fluid intake, initiated March 24, 2022. Observation in resident 63's room on August 15, 2023, at 9:44 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Further observation in Resident 63's on August 15, 2023, at 12:39 PM, revealed Resident 63 during lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Observation in Resident 63's room on August 16, 2023, at 9:54 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Further observation on August 15, 2023, at 12:45 PM, revealed Resident 63 during lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Interview with DON on August 17, 2023, at 11:48 AM, revealed she would expect the care plan to be followed and Resident 63 to have a water pitcher at bedside to promote fluid intake. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually, and that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 9, 10, 11, 12, and 13). Findings Include: Review of select facility documentation revealed that Employee 9 was hired on July 18, 2011; Employee 10 was hired on June 21, 2011; Employee 11 was hired on March 16, 2021; Employee 12 was hired on July 21, 2021; and Employee 13 was hired on December 30, 2021. During an interview with the Nursing Home Administrator on August 16, 2023, at 2:05 PM, he confirmed that no annual performance evaluations were completed for the aforementioned Employees since before June 2022. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy reviews, observations, completion of a meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing appearance, flavor, and temperature. Findings include: Review of facility document, titled Meal Service and Distribution last reviewed August 2, 2023, revealed Have hot food hot and cold food cold when the tray reaches that resident. Review of facility document, titled Dining and Food Service last reviewed August 2, 2023, revealed, The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve the provision of nourishing, palatable, attractive meals to meet the resident's daily nutritional and special dietary needs. Multiple resident interviews on August 14 and 15, 2023, revealed residents voiced concerns with the temperature and flavor of the food during meal service. During an interview with Resident 13 on August 14, 2023, at 10:35 AM, Resident 13 stated that sometimes the food is not always hot. Interview with Resident 30 on August 14, 2023, at 11:40 AM, revealed he is often served cold food. During an interview with Resident 34 on August 15, 2023, at 9:38 AM, Resident 34 stated that the food is not good. During an interview with Resident 36 on August 14, 2023, at 10:19 AM, Resident 36 indicated that the food was not too good; most of the time it is overcooked, and it is not always hot. Resident 36 further stated that condiments such as salt is not always on the tray. During an interview with Resident 82 on August 15, 2023, at 9:18 AM, when Resident 82 was asked about the food, he scrunched up his nose. Resident 82 stated the food was iffy and the temperature of the food is not good. Interview with Resident 84 on August 14, 2023, at 1:15 PM, revealed her family members bring her food often as facility food does not taste good and is often cold. Follow-up interview with Resident 84 on August 15, 2023, at 12:32 PM, during lunch meal, the Resident revealed the chicken was dry and salty. Immediate observation of the chicken on the plate revealed a dry appearance. During an interview with Resident 106 on August 14, 2023, at 11:02 AM, Resident 106 stated the food is not as good as it used to be. She further stated that the temperature of the food isn't to her liking, and the vegetables are often hard. Review of resident council meeting minutes from May 24, 2023, revealed residents voiced dietary concerns about potatoes and noodles needing to be cooked longer. Review of resident council meeting minutes from June 21, 2023, revealed residents voiced dietary concerns related to potatoes not being cooked long enough. Review of resident council minutes from July 18, 2023, revealed residents voiced concerns the iced tea needs more sugar, and the potatoes are still not being cooked long enough. Observation of dietary tray line service on August 16, 2023, at 11:46 AM, revealed chocolate pie portions stacked on top of each other causing pie served to residents to be smashed flat on the plate with an unattractive appearance. Observation of dietary tray line service on August 16, 2023, at 12:10 PM, revealed butter parsley noodles were running low and replaced with plain, not seasoned noodles. Interview with Employee 3 (Dietary Manager) on August 16, 2023, at 12:29 PM, revealed it is the facility's expectation that hot foods and beverages are served at or above 140 degrees Fahrenheit (unit of measure), and cold foods and beverages as served at or below 41 degrees Fahrenheit. A Test Tray was completed on August 16, 2023, at 12:34 PM, utilizing lunch tray served from tray line in the main facility kitchen. A test tray was served and placed in closed food cart for approximately two minutes prior to being delivered to third floor dining room area (other trays for room service being delivered here also at this time). The Test Tray included: meatballs with mushroom gravy, noodles, broccoli and cauliflower, chocolate pie, coffee, and milk. Temperatures taken by Employee 3 revealed the following: meatballs were 136 degrees Fahrenheit, not acceptable temperature broccoli and cauliflower were 132 degrees Fahrenheit, not acceptable temperature chocolate pie was 58 degrees Fahrenheit milk was 52 degrees Fahrenheit, not acceptable temperature, and coffee was 135 degrees Fahrenheit, not acceptable temperature The test tray included the plain noodles that were bland in taste, and the chocolate pie that was smashed flat on the plate with an unattractive appearance. Interview with Employee 3 on August 16, 2023, at 12:37 PM, revealed food and beverages should be served at attractive appearance, flavor, and temperatures. Interview with the Nursing Home Administrator on August 16, 2023, at 1:57 PM, revealed it is the facility's expectation that food and beverages are served at attractive appearance, flavor, and temperatures. 28 Pa. Code 211.6 (d) Dietary services

Based on resident and staff interviews, state regulations, record review, scope of practice, and facility policy, it was determined that the facility failed to follow professional standards of practice when providing medication administration to one of three residents reviewed (Resident 1). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. A review of the facility policy, titled Administering Medications no date, states, Medications must be administered in accordance with the orders, including any required time-frame. The policy also states, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident, or suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the Resident's Attending Physician or the facility's Medical director to discuss the concerns. A review of the clinical record for Resident 1 on June 22, 2023, at 5:00 PM, revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) . During an interview with Resident 1 on June 22, 2022, at approximately 4:15 PM, Resident 1 stated that she was not administered her Lasix (medication for edema) or the clonazepam (medication to treat her anxiety) on June 16, 2023, as ordered by the physician. Resident 1 also stated that she reminded the medication nurse at 3:30 PM that she hadn't received the clonazepam, but the nurse stated that it was too close to the next dose. Resident 1 stated that she requested the nurse to call the physician because he could approve administering the missed dose, but the nurse never administered the missed dose and Resident 1 stated the nurse would not call the physician. A review of Resident 1's Medication Administration Record (MAR) revealed orders for clonazepam 0.5 milligrams daily at 2:00 PM, and Lasix 20 milligrams daily at 1:00 PM. Further review of the MAR revealed that Resident 1 was not administered her clonazepam on June 16, 2023, at 2:00 PM. The MAR was coded that the Lasix was administered at 2:57 PM. The facility interviewed Employee 1 (Licensed Practical Nurse) who was administering medications on the afternoon of June 16, 2023. Employee 1 stated that she marked the Lasix in error and that it was not administered. Employee 1 also stated that she realized at the end of the day that she failed to click to the next page of the MAR, which detailed the order for clonazepam. Employee 1 stated that she informed the charge nurse and the charge nurse informed her to hold the medication as a nursing action. The Assistant Director of Nursing (ADON) stated Employee 1 worked until 5:00 PM on June 16, 2023. On June 22, 2023, the ADON provided email correspondence that revealed Employee 1 was re-educated on medication administration documentation, to administer all medications as ordered, and not to document a medication if not administered. On June 23, 2023, email correspondence from the Director of Nursing (DON) included a written statement by Employee 2 (Registered Nurse) who was the charge nurse on the afternoon of June 16, 2023. Employee 2 documented that Employee 1 informed her that the 2:00 PM clonazepam wasn't administered because she couldn't find Resident 1. Further review of Resident 1's care plan and clinical record failed to reveal that she has been evaluated to self-administer medications. During an interview with the ADON on June 22, 2022, at approximately 5:00 PM, she confirmed that Resident 1 should have received her Lasix and clonazepam as ordered. During correspondence with the DON on June 23, 2023, she stated that medications should be given as ordered by the physician depending on Resident availability. 28 Pa. Code 211.12(d)(1)(5)Nursing services