Based on review of facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for six of seventeen residents as required (Residents R3, R505, R500, R501, R502, and R504) on one of three nursing units and the main dining room. Findings included: Review of the facility policy Accommodation of Needs dated 3/12/25, indicated the resident has the right to a safe, clean comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The maintenance of comfortable sound levels. During an observation on 6/24/25, at 11:32 a.m. Resident R2's room was observed. A large box fan was present, actively blowing toward Resident R2's bed. Large amounts of dust were visible on the fan grill. During a resident group interview (Residents R505, R500, R501, R502, and R504) on 6/24/25, at 1:30 p.m., all five residents in attendance stated the kitchen staff slam the kitchen door when they enter or exit the kitchen. The residents stated, they slam the door on purpose. This is a daily occurrence during all three meals and during some activities. Residents reported they are uncomfortable and startled each time the door slams. Resident R505 stated, he discussed this with the Nursing Home Administrator (NHA) a couple of weeks ago and it continues to occur. During an observation on 6/25/25, between 9:35 a.m. through 9:37 a.m., of the kitchen entry/exit hallway door, slammed three times. Nearby staff was observed flinching. During an interview with Employee E2 at 9:37 a.m., when asked why she flinched, she stated it was the loud noise of the slamming door. Employee E2 was observed working down the hall from the door that had been slammed closed. During an observation with the NHA on 6/25/25, approximately 9:40 a.m., of the kitchen entry/exit hallway door, staff entered, and the door slammed shut. A demonstration of the door revealed it automatically slams closed on each entry/exit. During an interview with Maintenance Employee E1 on 6/26/25 at 8:15 a.m., revealed the kitchen staff had been told multiple times to keep the dining room door to the kitchen closed, as the vacuum will cause the hallway door to the kitchen to slam shut upon each entry/exit. During an interview on 6/25/25, at approximately 9:40 a.m., the Nursing Home Administrator confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment for six of seventeen residents as required (Residents R2, R22, R500, R501, R502, and R504) on one of three nursing units and the main dining room. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for four of eight residents (Resident R105, R109, R155, and R157). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days following admission. Resident R105 had an admission date of 6/9/25, with an MDS completion date of 6/23/25. Resident R109 had an admission date of 6/6/24, with an MDS completion date of 6/24/25. Resident R155 had an admission date of 6/9/25, with an MDS completion date of 6/23/25. Resident R157 had an admission date of 6/9/25, with an MDS completion date of 6/24/25. During an interview on 6/26/25, at approximately 12:30 p.m. the Director of Nursing confirmed that the above MDS assessments were completed late. During an interview on 6;26 at approximately 2:00 p.m. Nursing Home Administrator confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for four of eight residents. 28 Pa. Code: 211.5(f) Clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased capillary blood glucose (CBG) levels for one of four residents (R27). Findings: Review of the facility policy, Physician/Advanced Practice Provider Notification dated 3/12/25, indicated, Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will: - Perform appropriate clinical observations, - Collect pertinent patient information (e.g., age, diagnoses, prior vital signs, labs, recent changes in medications, previous incidents of a similar nature, code status, etc.), - Report to physician/advanced practice provider (APP). If unable to contact attending physician/APP, the Medical Director will be contacted. Review of the clinical record indicated Resident R27 originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes. Review of Resident R27's care plan initiated 7/30/22, for diabetes indicated to monitor for signs and symptoms of hyper/hypoglycemia (high/low blood sugar) and report abnormal findings to physician. Review of a physician order dated 6/26/24, indicated to inject Humalog insulin (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R27's blood sugar level was greater than 500 to call the MD (Doctor of Medicine). Review of Resident R27's blood sugar record revealed the following elevated blood sugar levels without documentation that the provider was notified: 4/18/25, at 5:46 a.m. - 500.0 mg/dL (milligrams per deciliter) 4/23/25, at 9:33 p.m. - 516.0 mg/dL 4/25/25, at 5:57 a.m. - 600.0 mg/dL 4/30/25, at 5:00 p.m. - 508.0 mg/dL 5/02/25, at 12:40 p.m. - 500.0 mg/dL 5/02/25, at 12:47 p.m. - 553.0 mg/dL 5/28/25, at 1:07 a.m. - 600.0 mg/dL 6/15/25, at 1:29 a.m. - 500.0 mg/dL 6/20/25, at 5:34 a.m. - 500.0 mg/dL During an interview on 6/26/25, at 10:08 a.m. the Director of Nursing confirmed that the clinical record failed to reveal a notification to the provider for the above blood sugar levels. During an interview on 6/26/25, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of increased and decreased capillary blood glucose levels for one of four residents. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of five residents (Resident R4 and R30). Findings include: Review of the United States Food and Drug Administration prescribing information for potassium chloride (extended release) dated October 2010, indicated, To take this medicine following the frequency and amount prescribed by the physician. This is especially important if the patient is also taking diuretics and/or digitalis preparations. Review of facility policy Medication Administration - Orals dated 3/12/25, indicated that medications are administered in an organized, accurate and safe manner. Review of Resident R30's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 5/2/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) and chronic kidney disease (gradual loss of kidney function). Review of a physician's order dated 4/28/25, indicated for Resident R30 to receive 10 mEq (milliequivalents) of extended-release potassium chloride at 10:00 a.m. and 10:00 p.m. Review of a physician's order dated 6/13/25, indicated for Resident R30 to receive 20 mg (milligrams) of furosemide (a diuretic medication) daily at 8:00 a.m. During an observation of a medication administration on 6/25/25, at approximately 8:44 a.m. Licensed Practical Nurse (LPN) Employee E5 was observed providing medication to Resident R30. During the observation it was noted that the order for potassium chloride was not highlighted, which indicated that it was not the correct time to administer the medication. During the medication administration, LPN Employee E5 provided 10 mEq of potassium chloride to Resident R30. LPN Employee E5 was unable to document that the potassium chloride was provided as the electronic medical record will not allow documentation of administration outside of the appropriate timeframes for the provision of the medication. Review of a medication audit report printed on 6/25/25, at 11:11 a.m. did not show an administration of potassium chloride to Resident R30. Review of Resident R30's medication audit report from 6/20/25, through 6/24/25 revealed the following related to the administration of potassium chloride: 6/20/25: 10:00 a.m. dose documented at 1:39 p.m. 6/22/25: 10:00 a.m. dose documented at 12:38 p.m. 6/23/25: 10:00 a.m. dose documented at 1:10 p.m. 6/24/25: 10:00 a.m. dose documented at 12:24 p.m. Review of Resident R1's admission record indicated admission to the facility on 5/19/24. Review of Resident R1's MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and a thyroid disorder. Review of a physician's order dated 5/20/24, indicated for Resident R1 to receive 10 mEq of extended-release potassium chloride daily at 10:00 a.m. Review of a physician's order dated 5/20/24, indicated for Resident R1 to receive 20 mg of furosemide at 8:00 a.m. Review of Resident R1's medication audit report from 6/20/25, through 6/24/25 revealed the following related to the administration of potassium chloride: 6/20/25: all medications scheduled at 8:00 a.m. and 10:00 a.m. were documented as provided at 1:30 p.m. 6/22/25: 10:00 a.m. dose documented at 12:38 p.m. 6/23/25: all medications scheduled at 8:00 a.m. and 10:00 a.m. were documented as provided at 9:21 a.m. and 9:22 a.m. 6/24/25: all medications scheduled at 8:00 a.m. and 10:00 a.m. were documented as provided at 10:09 a.m. and 10:10 a.m. 6/25/25: all medications scheduled at 8:00 a.m. and 10:00 a.m. were documented as provided at 9:09 a.m. and 9:10 a.m. During an interview on 6/26/25, at approximately 9:30 a.m. the Director of Nursing confirmed that the orders for potassium chloride were specifically scheduled outside of the normal medication pass time so the medication would not be given at the same time as the other medications. During an interview on 6/26/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents were free from significant medication errors for two of five residents. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(c) 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 and documents, clinical records, and staff interview, it was determined that the facility failed to make certain a resident was free from the use of a physical restraint without a physician's order for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Abuse Prohibition, reviewed 6/3/24, revealed that the facility prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Review of the facility policy, Restraints: Use of reviewed 6/3/24, indicated a physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: -Is attached or adjacent to the patient's body, -Cannot be removed easily by the patient, and -Restricts the patient's freedom of movement or normal access to their body. The policy further stated that there must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 8/5/24, included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and a leg/hip fracture. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5. Review of Resident R1's plan of care for behavior management, initiated 8/4/24, indicated the goal for Resident R1 to remain safe while in the facility. Review of a progress note written by Registered Nurse (RN) Employee E2 on 8/17/24, at 11:58 a.m. stated Received concern that resident had gait belt applied last weekend on 8/11/24 to torso. Resident assessed at this time for any injuries or negative outcomes from use of device to which none were noted on assessment. Resident has no change in demeanor nor does he demonstrate any fears or fearfulness. Review of documentation submitted by the facility on 8/17/24, revealed After receiving notice of allegation on August 17, 2024. The Director of Nursing started an investigation and statements obtained. The nurse [RN Employee E1] immediately suspended pending investigation. Adult Protective Services (APS) was notified, and spoke to an employee from APS. The Family of resident involved was notified of the incident as well as [attending provider]. Head to toe assessments including skin and pain completed on residents. Resident placed on User Defined Assessment (UDA) for change in condition. Resident has BIMS 5 and a history of repeated falls. Preventive measure for falls in place. Resident ambulates with 2 assists. The resident was last by CNA (NA - nurse aide) at meal time. The care plan was reviewed. Education provided to all nurses regarding the policy for Abuse, Neglect and restraints. All staff on hire are educated on abuse, neglect and restraints annually. Update (8/20/24): The RN did use a gait belt as a restraint. The gait belt was used to tie resident to chair. The resident was assessed for injury. The RN assessed the resident and he did not have any injury from the incident. The staff was educated immediately on Abuse, Neglect and restraints. The resident will be monitored closely and brought to the nurses station when needed for one on one. Review of a facility investigation statement dated 8/17/24, written by RN Employee E1 stated, Incident really started day prior when resident fell from low bed three times in two hours. This resident with Parkinson's with delusions and hallucinations No safety awareness recovering from a hip fracture he had sustained on a previous incident in our facility. Now with Covid. Had already failed all attempts by Occupational Therapy (OT) for any safe positioning device gerichair, wheelchair with dropseat, reclining wheelchair, pommel cushion as he kept sliding out of chair during trials in therapy. On Sunday so rigid from being flat in bed that initially he was unable to bend at waist to sit up for feeding. Did passive range of motion gaining some bend at waist with mechanical lift placed in gerichair where he once again assumed rigid posturing sliding out foot of chair. Unfortunately, we do not have enough staff to one on one which is what he really needed; Asked OT what to do. No suggestions Talked to son describing the dilemma that I did not know how to keep his father safe with his confusion, restlessness, unsteady gait and recent falls did discuss lap buddy explaining it would go between the arm of wheelchair to which he agreed. During an interview on 8/27/24, at approximately 1:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that facility failed to make certain a resident was free from the use of a physical restraint without a physician's order for one of three residents reviewed. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility documents, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of possible abuse for one of three residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of facility policy Abuse Prohibition, reviewed 6/3/24, revealed that the facility prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation. This includes freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The policy further stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. Review of the facility policy, Restraints: Use of reviewed 6/3/24, indicated a physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: -Is attached or adjacent to the patient's body, -Cannot be removed easily by the patient, and -Restricts the patient's freedom of movement or normal access to their body. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 8/5/24, included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and a leg/hip fracture. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5. Review of Resident R1's plan of care for behavior management, initiated 8/4/24, indicated the goal for Resident R1 to remain safe while in the facility. Review of a progress note written by Registered Nurse (RN) Employee E2 on 8/17/24, at 11:58 a.m. stated Received concern that resident had gait belt applied last weekend on 8/11/24 to torso. Resident assessed at this time for any injuries or negative outcomes from use of device to which none were noted on assessment. Resident has no change in demeanor nor does he demonstrate any fears or fearfulness. Review of documentation submitted by the facility on 8/17/24, revealed After receiving notice of allegation on August 17, 2024. The Director of Nursing started an investigation and statements obtained. The nurse [RN Employee E1] immediately suspended pending investigation. Adult Protective Services (APS) was notified, and spoke to an employee from APS. The Family of resident's involved was notified of the incident as well as [attending provider]. Head to toe assessments including skin and pain completed on residents. Resident placed on User Defined Assessment (UDA) for change in condition. Resident has BIMS 5 and a history of repeated falls. Preventive measure for falls in place. Resident ambulates with 2 assists. The resident was last by CNA (NA, nurse aide) at meal time. The Care plan was reviewed. Education provided to all nurses regarding the policy for Abuse, Neglect and restraints. All staff on hire are educated on abuse, neglect and restraints annually. Update (8/20/24): The RN did use a gait belt as a restraint. The gait belt was used to tie resident to chair. The resident was assessed for injury. The RN assessed the resident and he did not have any injury from the incident. The staff was educated immediately on Abuse, Neglect and restraints. The resident will be monitored closely and brought to the nurses station when needed for one on one. Review of a facility investigation witness statement dated 8/19/24, written by NA Employee E3 stated, August 11, 2024 I went on C hall to help pass trays and a CNA told me [Resident R1] was gaitbelt to wheelchair and I want back an looked, and came out and asked if [RN Employee E1] was aware and they said yes, because [RN Employee E1] did it. NA Employee E3 answered, Did you previously report the event or injury? (if yes, to whom did your report?) as Yes to the aide that worked c-hall and he said [RN Employee E1] was aware because [RN Employee E1] did it. Review of a facility investigation witness statement dated 8/19/24, written by NA Employee E4 stated, I was assigned to the hall and they stated that they were finding a chair buddy and [RN Employee E1] had put the gait belt around him to prevent him falling. At the time I was really busy and didn't stop to think. NA Employee E4 did not answer the question, Did you previously report the event or injury? (if yes, to whom did your report?). Review of a facility investigation witness statement dated 8/17/24, written by Licensed Practical Nurse (LPN) Employee E5 stated, On Sunday, RN charge nurse [RN Employee E1] obtained a gait belt from the therapy department. This gait belt was used to secure resident in [room number] in a chair. I did not witness the gait belt around the resident but the RN charge nurse did state that she placed it around him to keep him from sliding out of the chair. I was the nurse on skilled hall on 8-11-24. The resident was not in my care. LPN Employee E5 answered, Did you previously report the event or injury? (if yes, to whom did your report?) as No. Review of a facility investigation witness statement dated 8/19/24, written by NA Employee E6 indicated on 8/10/24, [Resident R1] had his light on I walked in the room and seen he was tied to the chair with a gait belt. He was was sliding out the chair so [LPN Employee E5] asked me to help pull him back up. NA Employee E6 answered, Did you previously report the event or injury? (if yes, to whom did your report?) as No. Review of a facility investigation witness statement dated 8/16/24, written by NA Employee E7 stated, I saw [Resident R1] on the floor, not on Sunday morning. Peers explained he was sitting on the [NAME] (geri) chair, strapped with a gait belt. Chair & gait belt were still in place from a couple hours earlier. NA Employee E7 answered, Did you previously report the event or injury? (if yes, to whom did your report?) as Yes with no name as to who it was reported to. Review of a facility investigation witness statement dated 8/17/24, written by NA Employee E8 stated, Did not witness but heard about. NA Employee E8 did not answer the question, Did you previously report the event or injury? (if yes, to whom did your report?). During an interview on 8/27/24, at approximately 1:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of possible abuse for one of three residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of two residents (Resident R12), by failing to follow physicians orders during transfer from a wheelchair into bed. This was identified as past non-compliance. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Abuse Prohibition last reviewed on 6/3/24, with a previous reivew date of 11/1/23, indicated that the center staff are doing all that is within their control to prevent occurrences of abuse, neglect, etc. The center must ensure that all staff are aware of reporting requirements. The investigation will be completed within 24 hours, the center will protect residents from further harm during the investigation, corrective action will be taken depending on the results of the investigation. Review of the clinical record indicated that Resident R12 was admitted to the facility on [DATE], with diagnoses which included kidney disease, bladder dysfunction, adult failure to thrive, chronic pain and sacral pressure ulcer. An MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 5/21/24, indicated the diagnoses remained current. Review of Resident R12's plan of care dated 5/24/24, indicated that Resident R12 was an extensive assist of two for transfers with use of a total lift. Review of an incident report dated 11/18/23, indicated that Resident R12 had told Registered Nurse(RN) Employee E1 that she had been transferred from her wheelchair to bed without use of the lift by Nurse Aide(NA) Employee E2 and NA Employee E3 which resulted in pain of her right lower extremity. Resident R12 stated that the identified Nurse Aides had worked the evening shift. Resident R12 was assessed by RN Employee E1 with identified pain ranked as a ten of ten with right ankle bruising and Resident R12's right leg internally rotated. The Medical Director and family were notified. Resident R12 initially refused to go to the hospital but did transfer later. Review of a statement dated 11/18/23, obtained from Resident R12's roommate Resident R300 indicated that she had overheard staff talking but could not identify what they said but that she knows that staff had transferred Resident R12 the previous week without use of the lift. Review of a statement dated 11/18/23, from NA Employee E3 indicated that on 11/17/23, she had identified that a lift pad was not underneath Resident R12 when she and NA Employee E2 had transferred Resident R12, they lifted her and put Resident R12 into bed, at the time Resident R12 did not indicated any pain but later did and NA Employee E3 told the RN on shift. Review of a witness statement dated 11/18/23, from NA Employee E2 indicated that on 11/17/23, she and NA Employee E3 had to put Resident R12 into bed as Resident R12 was not feeling well and was in pain. NA Employee E2 indicated that a sling pad was not under Resident R12 and NA Employee E2 indicated Resident R12 was assist of two and they put her into bed, and provided incontinence care. NA Employee E2 stated that by the time she and NA Employee E3 started second rounds, Resident R12 stated she was having right leg pain and she and NA Employee E3 went to get the RN. During an interview on 7/10/24, at 3:00 p.m. NA Employees E2 and E3 reiterated their statements and stated afterwards they asked the previous shift staff why Resident R12 did not have a sling pad under her in the chair and the staff stated they used a split pad NA Employee E2 stated that Resident R12 would never have let them use a split pad as they hurt her thighs and private areas. NA Employee E2 stated that they did not know why they were the only two suspended. Review of the disciplinary actions for NA Employee E2 and NA Employee E3 indicated suspension until the investigation was completed, they were provided re-training on lift use and use of the [NAME]/care plan. Review of the facility plan of correction dated 11/20/23, indicated a review of all resident transfers with identification of resident's requiring lifts, pads used and making certain each resident had the pads available for use. Review of the facility plan of correction dated from 11/18/23, thorough 11/20/23, indicated a nursing staff re-education related to review of care plan/[NAME] and use of following resident orders for transfer. During an interview on 7/10/24, at 2:10 p.m., the Director of Nursing and Administrator confirmed that the facility failed to protect residents from neglect for one of two residents (Resident R12), by failing to follow physicians orders during transfer from a wheelchair into bed. The facility has demonstrated compliance with the regulation since 11/20/23. During an interview on 7/10/24, at 2:10 p. m., with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for three of seven Residents (Residents R5, R30, R37). Findings: Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and anxiety. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/1/24, indicated the diagnoses remain current. Review of a physician order dated 5/29/24, revealed Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin, 7 units once a day, if greater than 350 move to a medium scale two times a day. On 7/1/24, Lantus (long-acting type of insulin that works slowly, over about 24 hours), 37 units once daily. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 5/8/24, at 4:24 p.m. CBG was noted to be 41. On 5/25/24, at 4:48 p.m. CBG was noted to be 52. On 6/1/24, at 4:47 p.m. CBG was noted to be 67. On 6/2/24, at 5:58 a.m. CBG was noted to be 63. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 5/22/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Review of the clinical record revealed Resident R30 was admitted to the facility on [DATE], with diagnoses that included diabetes, end-stage renal disease (kidneys lose the ability to remove waste and balance fluids), muscle weakness. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 6/5/24, indicated the diagnoses remain current. Review of a physician order dated 6/24/24, revealed Humalog insulin, 2 units three times a day, Humalog sliding scale with result greater than 450 give additional 14 units. A physician order dated 3/20/23, revealed Lantus 22 units daily. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 7/3/24, 6:20 a.m. CBG was noted to be 407. On 7/3/24, 4:10 p.m. CBG was noted to be 61. On 7/6/24, 6:18 a.m. CBG was noted to be 400. On 7/10/24, 6:12 a.m. CBG was noted to be 477. On 7/11/24, 6:23 p.m. CBG was noted to be 67. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 3/29/23, 5/9/23, and 6/24/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Review of the clinical record revealed Resident R37 was admitted to the facility on [DATE], with diagnoses that included diabetes, muscle weakness and chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 5/15/24, indicated to inject Novolog insulin per sliding scale, if over 400 give 10 units, call physician if greater than 450. A physician order dated 1/19/24, revealed Lantus 18 units daily. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 5/23/24, at 6:36 a.m. CBG was noted to be 69. On 6/3/24, at 6:48 a.m. CBG was noted to be 70. On 6/14/24, at 8:00 p.m. CBG was noted to be 402. On 6/15/24, at 6:20 a.m. CBG was noted to be 61. On 6/15/24, at 4:20 p.m. CBG was noted to be 412. On 6/20/24, at 11:56 a.m. CBG was noted to be 468. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow physician ' s order, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 5/22/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed signs and symptoms of hypo-/hyperglycemia. During an interview on 7/11/24, at approximately 8:30 a.m. Licensed Practical Nurse (LPN) Employee E4 stated for residents without diabetic parameters they would notify the doctor for blood glucose levels under 70, assess if unresponsive give Glucagon (medicine to increase blood sugar), if responsive give glucose gel, or over 450, give insulin per order, call doctor and document in progress notes. During an interview on 7/12/24, at 9:10 a.m. LPN Employee E5 stated for residents without ordered diabetic parameters they would notify the doctor if blood glucose was under 70, or over 450. They would follow facility protocol for low results, and if it was high, they would give the ordered insulin and notify the charge nurse for either level parameter. During an interview on 7/12/24, at 9:16 a.m. LPN Employee E6 stated for residents with ordered parameters of blood glucose results were under 70, or over 450, they would follow facility protocol. If it was low, they would start the facility protocol, call the doctor and the RN (registered nurse) supervisor, and recheck the blood glucose in 15 minutes. They would document the incident in the progress notes and the eMAR. During an interview on 7/12/24, at 9:15 a.m. the Director of Nursing (DON) confirmed the facility failed to provide timely and complete communication to a physician when there was a change in condition. The DON confirmed the facility failed to recognize, assist and document the treatment of complications commonly associated with diabetes. Documentation should reflect the carefully assessed diabetic resident for vital signs, skin (color, temperature, dryness, sweating, irritation or abrasions), percentage of meals consumed, mood changes, pain, restlessness, numbness/tingling, results of any fingerstick, interventions to stabilize the blood glucose levels and response, notification of physician of unstable or significant variances from base line per physician order. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with hospice services (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) center for two of two residents receiving hospice (Resident R13 and R49). Findings include: A review of the facility policy Hospice last reviewed 4/26/23, indicated the hospice will provide a communication process, including the method for documenting the communication between the center and the hospice provider to ensure that the patient's needs are met 24 hours per day A review of the clinical record indicated that Resident R13 was admitted to the facility on [DATE], with diagnoses that included iron deficient anemia secondary to chronic blood loss, chronic kidney disease, and failure to thrive. A review of a physician's order dated 11/23/22, indicated Resident R13 was admitted to hospice services. Review of a care plan indicated that hospice staff will visit to provide care, assistance, and evaluations. Review of the clinical record revealed the last documented hospice communication with the facility was on 5/23/23. A review of the clinical record indicated that Resident R49 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning), acute and chronic respiratory failure, and congestive heart failure (a condition in which the heart doesn't pump as well as it should). A review of a physician's order dated 10/25/22, indicated Resident R49 was admitted to hospice services. Review of a care plan indicated that hospice staff will visit to provide care, assistance, and evaluations. Review of the clinical record revealed the last documented hospice communication with the facility was on 7/13/23. During an interview on 8/11/23, at 2:30 p.m. the Director of Nursing confirmed there were not consistent communication notes for Resident R13 and R49 for hospice visits and services. 28 PA Code: 211.10(c)(d) Resident Care Policies 28 PA Code: 201.18 (b)(1)(e)(1) Management. 28 PA Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident for five of eight residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of the facility policy Abuse Prohibition reviewed on 4/26/22, indicated the facility will implement an abuse prohibition program including investigation of possible incidents and allegations to ensure facility staff are doing all that is within their control to prevent abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Injuries of unknown origin are defined as a source of injury that was not observed by any person or cannot be explained by the patient, and is suspicious due to the location, number of injuries, extent of the injuries. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression and high blood pressure. A review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 2/24/23, indicated the diagnoses remain current. A review of the Brief Interview for Mental Status (BIMS- evaluation aimed at assessing aspects of cognition in elderly patients) score was 99, indicating severe cognitive impairment. A review of facility records indicated Resident R1 sustained an injury on 4/10/23, to his elbow. It was not known how the injury occurred. A review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included stroke, slurred speech, seizures, and difficulty swallowing. A review of facility records indicated Resident R2 had an incident of unknown cause occur on 3/22/23, she was sent to the hospital. An investigation was not completed. A review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included Alzheimer ' s Disease (brain disorder that causes problems with memory, thinking and behavior), difficulty swallowing, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 99, indicating severe impairment. A review of facility documents indicated Resident R3 had a choking incident on 3/10/23, and the Heimlich maneuver was performed. A review of the clinical record indicated Resident R4 was admitted to the facility on [DATE], with diagnoses that included depression, diabetes, and anxiety. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 13, indicated no impairment. A review of the facility records indicated Resident R4 sustained a skin tear under her right breast skin fold on 2/12/23. Resident R4 stated she did not know how it happened. A review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included Cerebral Palsy (group of disorders that affect movement, muscle tone, balance, and posture), seizures, and depression. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the BIMS score was 99, indicating severe impairment. A review of the facility records indicated Resident R5 sustained an unwitnessed bruise to the right side of his face. During an interview on 4/13/23, at 3:24 p.m. the Director of Nursing confirmed that the incident's were not fully investigated, no cause, or conclusion were considered or eliminated for the incidents for Residents R1, R2, R3, R4, and R5. 28 Pa. Code: 201.149(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Based on review of facility menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for one of one lunch meal (lunch meal Thursday 4/13/23). Findings include: A review of the menu indicated that the menu for lunch was as follows: Cream of Potato Soup Italian Sub Sandwich Snickerdoodle Cookie Creamy Coleslaw During an observation of lunch meal service in the main dining room on 4/13/23, at 12:20 p.m., it was revealed that all of the residents(18) had the following instead: Ham Sandwich (on Bread) French Fries Snickerdoodle Cookie Coleslaw Mixed Vegetables During an interview on 4/14/23, at 12:15 p.m. Dietary [NAME] Employee E1 confirmed that was a different menu. She stated The truck hasn't come in yet, I know what the resident's like. During an interview on 4/14/23, at 4:45 p.m. the Nursing Home Administrator confirmed that the facility failed to serve what was on the menu and failed to reflect menu changes. 28 Pa. Code: 211.6(a)(b) Dietary services.

Based on staff interviews it was determined that the facility failed to employ a full-time director of food service for one of one month (March 2023). Findings include: During a kitchen tour on 4/14/23, at 11:15 a.m., Dietary [NAME] Employee E1 stated the kitchen has not had a manager for about three weeks. During an interview on 4/14/23, at 4:20 p.m. the Nursing Home Administrator confirmed that the facility has not had a Dietary Manager since 3/13/23, as required, the Registered Dietitian is here one day per week and the District Manager one day per week. 28 Pa. Code 201. 18(e)(1)(6)Management. 28 Pa. Code 211. 6(c) Dietary services.