**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident or representative for two of 18 sampled residents. (Residents 17, 64) Findings include: Review of the facility policy entitled, Baseline Care Plan, dated January 20, 2025, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include healthcare information necessary to properly care for a resident and must include initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan will include trauma-informed care goals and interventions under the psychosocial well-being care plan if identified immediately upon admission, and the resident and/or representative were to be provided a written summary of the baseline care plan. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE]. The baseline care plan was developed on April 10, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. Clinical record review revealed that Resident 64 was admitted to the facility on [DATE]. The baseline care plan was developed on January 22, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. During an interview on April 30, 2025, at 2:30 p.m., the Administrator confirmed that there was no evidence the baseline care plan summary was provided to the residents and/or their representatives. 28 Pa. Code 201.18 (b)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, group interview, staff interview, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for seven of 18 sampled residents. (Residents 42, 45, 54, 56, 73, 77, 82) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included radiculopathy (compressed nerve in the spine that cause pain), muscle weakness, and difficulty walking. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 54 had diagnoses that included congestive heart failure, diabetes, muscle weakness, and late onset Alzheimer's disease. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 56 had diagnoses that included post polio syndrome (condition that causes gradual muscle weakness) and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting, dressing, and personal hygiene. Clinical record review revealed that Resident 73 had diagnoses that included Parkinson's disease and neuromuscular dysfunction of bladder (urinary bladder problems due to a disease). The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. During a group interview on April 30, 2025, at 10:00 a.m., Residents 45, 54, 56, and 73 reported that it took long periods of time (30 minutes or more) for staff to answer their call bells and get assistance. Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 10:38 a.m., Resident 42 stated that staff took a long time to answer call bells which has affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 77 had diagnoses that included a history of traumatic injuries, peripheral vascular disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:00 a.m., Resident 77 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. Clinical record review revealed that Resident 82 had diagnoses that included partial paralysis to the right side following a stroke, chronic kidney disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:55 a.m., Resident 82 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. In an interview on April 30, 2025, at 1:00 p.m., the Administrator revealed that staff were expected to respond to a call light within 15 minutes or less. Review of the facility form entitled, Device Activity Report, for Residents 42, 45, 54, 56, 73, 77, and 82, revealed that from April 1 through April 30, 2025, there were 158 occurrences when the call bell response time exceeded 15 minutes which included: April 2, 2025, at 7:39 p.m., Resident 42 waited 68 minutes; April 7, 2025, at 12:37 a.m., Resident 45 waited 58 minutes; April 9, 2025, at 7:36 a.m., Resident 54 waited 91 minutes; April 20, 2025, at 8:16 a.m., Resident 56 waited 20 minutes; April 22, 2025, at 3:46 a.m., Resident 73 waited 65 minutes; April 14, 2025, at 1:53 a.m., Resident 77 waited 168 minutes; and April 9, 2025, at 8:02 a.m., Resident 82 waited 41 minutes. During an interview on May 1, 2025, at 10:45 a.m., the Administrator confirmed the aforementioned residents waited more than the expected response time of 15 minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 21 sampled residents. (Residents 47, 60) Findings include: Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], and had diagnoses that included diabetes mellitus and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident had impaired vision and required corrective lenses. The Care Area Assessment (CAA) indicated that vision was to be addressed in the care plan. There was no evidence that interventions to address Resident 47's vision were included in the current care plan. Clinical record review revealed that Resident 60 was admitted to the facility on [DATE], and had diagnoses that included a risk for impaired vision and optic nerve damage (glaucoma), an abnormal gait when walking, and a history of falling. The MDS CAA summary dated February 8, 2024, noted that the resident's vision was to be addressed in the care plan. There was no evidence that interventions to address Resident 60's vision were included in the current care plan. In an interview on April 25, 2024, at 11:05 a.m., the Nursing Home Administrator confirmed that the identified care areas were not addressed in residents 47's and 60's current care plans. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on clinical record review, review of facility documentation, resident interview, and staff interview, it was determined that the facility failed to thoroughly investigate a fall for one of four sampled residents identified at risk for falls. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included congestive heart failure and osteoporosis. Review of the current care plan revealed that Resident 1 was at risk to fall due to muscle weakness and needed staff assistance for activities of daily living, including dressing and incontinence care. Review of the Minimum Data Set assessment completed on November 9, 2023, indicated that Resident 1 did not have impaired cognition. On January 11, 2024, a nurse (RN 1) noted that she was walking by the resident's room and saw Resident 1 sitting on the floor with her left lower leg extended behind her. RN 1 noted a nurse aide (NA 1) who was in the room stated that, She didn't fall. She just lowered to the ground. She wanted me to hold her up and I said that she needs to stand. I can't stand here and hold her up. Review of facility documentation revealed that Resident 1 stated, I told that girl I needed help to stand and she didn't help me. I can't stand on my own. I'm too weak and needed help. A statement from NA 1 on January 11, 2024, indicated that she came to change the resident at 7:00 a.m. and that she put the recliner chair up to help Resident 1 stand with her walker in front of her. NA 1 was trying to clean the resident and change her incontinence pad. She got the resident's brief and the resident slipped on the floor. She asked me to hold her but she was already on the floor. An interdisciplinary team fall review note dated January 12, 2024, stated that the resident was assisted to stand using a walker and lifting of a recliner chair. The NA attempted to provide incontinence care to Resident 1 at that time. Resident 1's left leg slipped out from under her and staff attempted to assist Resident 1 to the ground. Further review of facility documentation revealed that a statement was obtained from NA 2 on January 11, 2024. NA 2 stated that she heard RN 1 ask Resident 1 if she fell and then entered Resident 1's room. Resident 1 was on the floor and her left leg was in a weird position. NA 1 was in Resident 1's room. When NA 1 left the room, Resident 1 told NA 2 that NA 1 let her fall. Resident 1 told NA 2 that NA 1 was trying to change her while she was standing and that she told NA 1 that she could not stand any longer. NA 1 wasn't supporting her and did not have a hand on her. Another statement from NA 1 was obtained on January 12, 2024. She stated that Resident 1 was sitting in her recliner chair and she brought it higher to make it easier for her to stand with her walker in front of her. At the same time, RN 1 came in the room and NA 1 asked RN 1 if she could assist her in changing Resident 1's incontinence pad. She stated RN 1 turned and walked away so she turned away quickly to grab a washcloth and as she was grabbing the washcloth, she saw Resident 1's right leg giving out and before she knew it, she was on the ground. She stated she was holding Resident 1 the entire time and that she never refused to hold her up. In an interview on January 25, 2024, at 1:00 p.m., Resident 1 stated that during the incident NA 1 did not assist her or touch her prior to her fall and that she had told NA she was weak and could not stand. Further review of facility documentation revealed that interventions implemented after the fall were a call don't fall sign by Resident 1's recliner and in her bathroom to remind her to call for help during the night when she needs to transfer or ambulate. There was no documented evidence that the facility thoroughly investigated the reported inconsistencies in order to determine the circumstances of Resident 1's fall and implement appropriate interventions. 28 Pa. Code 211.12(d)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and observation, it was determined the facility failed to ensure that use of a physical restraint was medically justified and failed to conduct an on-going assessment of a restraint for one of 21 sampled residents. (Resident 62) Findings include: Review of the facility policy entitled, Restraint Policy, dated July 25, 2022, revealed that the interdisciplinary team would review and re-evaluate the use of all restraints ordered by physicians. The review would focus on the success or failure of the implementation of the plan, documentation, and recommendations for change if a problem was not resolved. The residents would be followed every 30 days or sooner until the restraint was eliminated or the least restrictive device was found to resolve the area of concern. Further review of the policy revealed that a physician's order must be obtained for use of a restraint and the order would indicate the type of restraint, the specific medical reason for its use, and frequency. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance with dressing and toileting. On May 24, 2022, the physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and remove promptly in the morning. The physician's order did not indicate the specific medical reason for the use of the jumpsuit. Review of the care plan revealed Resident 62 was at risk for behavioral symptoms. Interventions included for staff to apply a jumpsuit in the evening and remove it in the morning when the resident awoke. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed out of bed wearing a one piece jumpsuit that zipped down the back on the nursing unit. The jumpsuit limited his access to his own body and staff assistance was required to put on and take off the jumpsuit. Review of monthly restraint evaluation forms from December 2022 through April 2023, revealed that there was no documented evidence that the interdisciplinary team reviewed or re-evaluated the use of Resident 62's restraint to determine if it was the least restrictive device. 28 Pa. Code 211.8(e)(f) Use of restraints. 28 Pa. Code 201.12(d)(1)(5) 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 that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 21 sampled residents. (Residents 52, 62) Findings include: Clinical record review revealed that Resident 52 had diagnoses that included fracture left hip and anxiety. Section B of the MDS assessment dated [DATE], indicated that the resident was not in a vegetative state and that the resident's hearing, speech, and vision should be assessed. The MDS indicated Resident 52's hearing, speech, and vision were coded as not assessed. In an interview on May 11, 2023, at 11:19 a.m., the Administrator stated that Resident 52's hearing, speech, and vision should have been assessed. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. On May 24, 2022, a physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and to remove promptly in the morning. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed wearing a jumpsuit that zipped down the back that restricted the resident's movement. Section P of the MDS assessment dated [DATE], indicated that the resident did not use a restraint device. In an interview on May 11, 2023, at 11:25 a.m., the Administrator confirmed that Section P of the MDS indicated that Resident 62 did not use a restraint device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 21 sampled residents. (Resident 75, 88) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had cognitive impairment. The Care Area Assessment (CAA) summary, identified that cognitive loss/dementia was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address Resident 75's cognitive loss/dementia. Clinical record review revealed that Resident 88 had diagnoses that included depression and anxiety. Review of the MDS assessment dated [DATE], identified that the resident received psychotropic medications. According to the CAA summary, the facility identified that the resident's psychotropic medication use was a problem and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop a care plan with interventions to address the need for psychotropic medications. In an interview conducted on May 11, 2023, at 11:59 a.m., the Administrator confirmed that there was no care plan developed with interventions to address the above problem areas for Residents 75 and 88. 28 Pa. Code 211.11(d) Resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide services to increase range of motion and/or prevent further decrease in range of motion for one of 21 sampled residents. (Resident 75) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and difficulty in walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff for activities of daily living, such as transferring, moving in bed, and dressing. A physical therapy Discharge summary dated [DATE], noted that staff were to implement a restorative nursing program for ambulation of 25 to 100 feet. There was a lack of documentation to support that the physical therapist's recommendation for a restorative walking program was implemented for Resident 75. During an interview on May 11, 2023, the Therapist confirmed that there was no documentation that the restorative walking program for Resident 75 was implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.