Based on observation, clinical record review, and staff interview, it was determined that the facility failed to accurately assess the dental status of one of two residents reviewed for dental services (Resident 64). Findings include: Review of Resident 64's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and congestive heart failure (decreased ability of the heart to pump blood through the body). During a resident interview on November 4, 2024, it was observed that Resident 64 appeared to have no natural teeth. Review of a physician assessment conducted on October 10, 2024, revealed the physician noted Resident 64 was edentulous (without teeth). Review of Resident 64's admission Minimum Data Set (MDS - standardized assessment utilized to identify a residents' physical, psychological, and psychosocial needs), with an assessment reference date of October 4, 2024, revealed that section L - Oral/Dental Status, was not accurately coded for L0200 Dental, B. No natural teeth or tooth fragments (edentulous). During a staff interview on November 6, 2024, at approximately 10:30 AM, Nursing Home Administrator and Director of Nursing confirmed that Resident 64 did not have any natural teeth and that Resident 64's admission MDS was coded incorrectly. 28 Pa code 211.12(d)(5) Nursing services

Based on observations, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 19 residents reviewed (Resident 61). Findings include: Review of Resident 61's clinical record revealed diagnoses that included Parkinson's disease (progressive brain disorder that causes unintended or uncontrolled movements) and lack of coordination (difficulty controlling movements of the body). During an interview on November 3, 2024 at 10:37 AM, with Resident 61's Responsible Party, it was revealed that Resident 61 used an electric recliner and that the facility had taken the remote, preventing Resident 61 from being able to recline when sitting in the chair. Review of Resident 61's comprehensive plan of care revealed a focus area for impaired function of daily living due to Parkinson's with an intervention to recline chair and to put adjusting remote in pouch to chair. During an interview on November 5, 2024 at 12:15 PM, with the Director of Nursing (DON), it was revealed that Resident 61 recently had a fall after sliding out of the recliner due to not being able to work the remote and put the footrest down independently when reclined. The DON also revealed that due to Resident 61's cognitive level and inability to independently operate the chair's remote, that reclining Resident 61's chair would be considered a restraint and the remote was removed. An email on November 5, 2024 at 4:43 PM, from the NHA revealed that Resident 61's comprehensive plan of care should have been updated to reflect elevating Resident 61's legs as needed and removing the chair's remote from the room for safety. The NHA stated a care plan revision would be done. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide nutritional supplements as ordered by the physician for one of six residents observed during medication administration observations (Resident 4), and failed to to notify the physician of a significant weight change for one of five residents reviewed for nutrition (Resident 54). Findings include: Review of facility policy, titled Weight Record Monitoring, last revised August 2024, read, in part, The physician and resident's responsible party are notified by the RD/designee of significant weight change (gain or loss) and of the IDT recommendations that would require further intervention/securing of new orders from the physician for the resident. Review of Resident 4's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and diabetes type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 4's physician orders revealed an order dating March 18, 2024, for a dietary supplement (house supplement) three times a day, 4 ounces, between meals for the indication of poor meal intake. During medication observations conducted on November 5, 2024, at approximately 10:00 AM, Employee 9 was observed preparing medications for Resident 4. During preparation, Employee 9 was observed pouring approximately 8 ounces of chocolate milk in a cup. Employee 9 then stated, I usually give chocolate milk instead of the shake, the nutritional shake, because [the residents] usually like it more. Review of the nutritional value of the chocolate milk revealed the chocolate milk did not offer an equivalent nutritional value when comparable to the house supplement that Resident 4 was ordered. During a staff interview on November 5, 2024, at approximately 10:30 AM, Nursing Home Administrator (NHA) revealed that chocolate milk should not have been used as a substitute to the house supplement that Resident 4 was ordered. Review of Resident 54's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), muscle weakness, and Alzheimer's disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 54's clinical record revealed she had a significant weight loss of 5.7% in one month from September to October 2024. Further review of Resident 54's clinical record revealed a nutrition assessment in response to the weight loss that stated Medical Doctor to be notified. During an email correspondence with the NHA on November 4, 2024, at 12:17 PM, the surveyor requested information related to a physician notification of Resident 54's weight loss. Follow-up interview with the NHA on November 5, 2024, at 10:28 AM, revealed she is unable to locate any documentation to indicate the physician was notified of the weight loss, that her last physician assessment was prior to the noted weight loss, and she would expect that documentation to be available. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 18 Residents reviewed (Resident 12). Findings include: Review of Facility Policy, titled Trauma Informed Care Standard, with an effective date of November 1, 2019, read, in part, Definition: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social and emotional, or spiritual well-being. Events- can include actual or extreme threat or harm, or severe, life-threatening neglect for a child. Factors include: How an individual assigns meaning to the event. For residents: Initial screening on admission and with plan of care review, to determine if there may be a history of trauma. (See Getting to know our residents or guest form #8-204A). If identified, follow-up screening will occur to support development of the plan of care. Review of Resident 12's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and muscle weakness. During an interview with Resident 12 on November 3, 2024, at 11:22 AM, she was discussing her history of her career, but then started to become tearful as she stated she experienced childhood trauma. Review of Resident 12's care plan failed to reveal notification of having a history of trauma. Further review of Resident 12's care plan revealed she had a care plan focus area for depression and anxiety, with an intervention for arrange for psychiatric or psychological consult, follow up as indicated, with a start date of December 13, 2022. During an email correspondence with the Nursing Home Administrator (NHA) on November 3, 2024, at 12:57 PM, the surveyor revealed her interview with Resident 12 regarding her trauma, and requested information if that had been previously assessed, and if she follows with psychology services. Review of Resident 12's Psychosocial Assessment document provided dated December 13, 2022, failed to reveal questions regarding if the Resident had experienced a history of trauma, other than Describe significant life events over the past year. Review of Resident 12's PsychoGeriatric Services notes provided from May 22, 2024, and September 17, 2024, failed to reveal notation of a history of trauma. During an interview with the NHA and Employee 6 (Social Services Director) on November 5, 2024, at 10:28 AM, the surveyor inquired if there are any PsychoGeriatric Services assessing her history of trauma, or if the form mentioned in the facility policy is utilized the assess a history of trauma for residents upon admission. Interview with the NHA and Employee 6 on November 6, 2024, at 10:31 AM, revealed they are unable to locate documentation to indicate Resident 12 was assessed for her history of trauma. Follow-up email correspondence with the NHA on November 7, 2024, at 9:23 AM, revealed the facility is moving away from utilizing the form mentioned in the trauma informed care policy, they instead use a different form titled Psychosocial Assessment that assesses for a history of trauma. No further information was provided. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.10(a) Resident care policies

Based on review of facility policy, observations, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four residents on transmission-based precautions (Residents 61). Findings include: Review of facility policy, titled Transmission Based Precautions, with a revision date of June 2024, read, in part, I. Enhanced Barrier Precautions (EBP): is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and MDROs. G. Enhanced Barrier Precautions b. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds or indwelling medical devices, regardless of MDRO colonization status .g. gowns and gloves required when performing high-contact resident care activities associated with MDRO transmission (e.g. dressing, bathing, showering, toileting, transferring, changing linens, etc.). Review of Resident 61's clinical record revealed diagnoses that included parkinsons's disease (chronic, progressive brain disorder that affects movement and other parts of the body) and muscle weakness (loss of muscle strength). Review of Resident 61's physician orders revealed orders for wound care and enhance barrier precautions (EBP). An observation on November 3, 2024, at 10:34 AM, of Resident 61's room revealed signage indicating EBP and a personal protective equipment (PPE) caddy containing gowns and gloves. Observations made on November 6, 2024, at 9:45 AM, of Resident 61's wound care and dressing change revealed Employee 7 and Employee 8 failed to don gowns while performing high-contact Resident care. During an interview on November 6, 2024, at 10:00 AM, with Employee 7, revealed that Resident 61 is on EBP and gowns should have been worn. An interview on November 6, 2024, at 10:40 AM, with the Nursing Home Administrator, Director of Nursing, and Employee 1, revealed it was the facility's expectation that employees wear appropriate PPE. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa. Code 211.10 (d) Resident care policies

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that five residents have the right to a dignified dining experience during meal service in one of one dining rooms observed (Residents 9, 17, 24, 35, and 64). Findings include: Review of facility policy, titled Residents Rights Standard, read, in part, All residents in long term care maintain the same rights assured all Americans under Federal and State law. This standard is intended to assure each resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. Observations in the main dining room on November 3, 2024, between 11:34 AM and 12:02 PM, revealed Employee 4 (Dietary Employee) was serving tables throughout the dining room without completing one table at a time. The following observations were also made in the dining room during that time: Observation on November 3, 2024, at 11:34 AM, revealed Resident 26 was sitting at a table with Resident 35. Resident 26 had been previously served but Resident 35 was sitting without food, and Employee 4 was serving other tables. Observation on November 3, 2024, at 11:35 AM, Resident 35 was observed to state to Employee 4 could you get me something to eat please? During an interview with Resident 35 on November 3, 2024, at 11:37 AM, she revealed she is never sure when and if she is going to be served when she eats in the dining room. Resident 35 was observed to be served at 11:40 AM. Observation on November 3, 2024, at 11:34 AM, revealed Residents 17 and 56 were sitting at a table together, and Resident 56 had been previously served. Resident 17 was observed to be served at 11:42 AM. Observation on November 3, 2024, at 11:34 AM, revealed Residents 9, 27, and 46 were sitting at a table together, Resident 27 and 46 had been previously served. Observation on November 3, 2024, at 11:40 AM, revealed Resident 9 was observed to state where is my meal? I have been here since 11:00 AM. Resident 9 was observed to be served at 11:43 AM. Observation on November 3, 2024, at 11:36 AM, revealed Residents 2, 37, and 64 were sitting at a table together, Resident 2 and 37 had been previously served. Observation on November 3, 2024, at 11:43 AM, revealed Resident 64 was observed to state to Employee 10 did you fix mine yet? Resident 64 was observed to be served at 11:45 AM. Observation on November 3, 2024, at 11:35 AM, revealed Residents 3, 24, and 28 were sitting at a table together, Resident 3 and 28 had been previously served. Resident 24 was observed to be served at 11:53 AM. During an interview with the Nursing Home Administrator on November 4, 2024, at 1:39 PM, she revealed her expectation that residents would be served considering dignity during meal service. 28 Pa Code 201.29(d) Resident Rights

Based on observation, clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered plan of care for four of 19 residents reviewed (Residents 44, 48, 57, and 64). Findings Include: A review of the facility's policy, titled Comprehensive Care Planning Standard, revised November 15, 2017, read Each .center will develop a comprehensive care plan for each resident that includes their strengths, measurable objectives and timetables. Goal is to meet a resident's medical, nursing (physical/symptom control), mental, intellectual, emotional, social, spiritual, psychosocial and cultural needs that are identified during baseline care planning and in the comprehensive assessment. Care Plans are formatted in the 'I Care Plan' format to ensure resident centered/resident directed living. Review of Resident 44's clinical record revealed diagnoses that included chronic venous hypertension with ulcer of the left and right lower extremity (damage to veins that prevent blood from flowing back to the heart causing increased blood pressure, ulcers, swelling, and pain in the legs) and type two diabetes mellitus (the bodies inability to use insulin to process blood sugar for energy). Review of Resident 44's physician orders revealed orders for bilateral lower extremity ace wraps for edema (swelling) to be applied in the morning and taken off at night. Further review of Resident 44's physician orders also revealed orders for spironolactone (diuretic used to help the body remove excess fluid) and furosemide (diuretic used to help the body remove excess fluid) once daily for edema. Review of Resident 44's comprehensive plan of care failed to revealed focus areas or interventions for edema, bilateral leg wraps, and diuretic use. An email communication on November 6, 2024 at 9:11 AM, with the Nursing Home Administrator (NHA), revealed Resident 44's comprehensive plan of care should have been updated to include edema, bilateral legs wraps, and diuretic use and that a revision had been done. A review of Resident 48's clinical record revealed diagnoses that included bilateral cataracts (a clouding of the lens inside the eye, which normally is clear, causing blurry or cloudy vision due to the obstruction of light passing through to the retina; cataracts are most commonly associated with aging and can lead to blindness if left untreated) and hypertension (elevated blood pressure). An interview with Resident 48 on November 3, 2024, at 10:01 AM, revealed she needed cataract surgery and is awaiting the surgery to be scheduled. A review of Resident 48's interdisciplinary plan of care revealed no documentation of the Resident's visual function, bilateral cataracts, or staff interventions to assist the Resident with her visual function as needed. Electronic mail correspondence with the Nursing Home Administrator (NHA) on November 5, 2024, at 2:42 PM, revealed a vision care plan for Resident 48 was created and had now been added to the Resident's clinical record. A review of Resident 57's clinical record revealed diagnoses that included muscle weakness, abnormality of gait (a person's manner of walking), and mobility (the ability to move or be moved freely and easily). An observation of Resident 57 while in bed revealed bilateral enabler bars attached to the bed. A review of Resident 57's device review evaluation dated October 31, 2024, revealed the need for the use of the enablers for bed mobility. A review of Resident 57's interdisciplinary plan of care revealed no documentation of the Resident's need or use of those bilateral enabler bars. An interview with the facility's Corporate Excellence Nurse on November 6, 2024, at 10:36 AM, revealed no enabler care plan was in place, but has now been developed and added to the Resident's clinical record. A review of Resident 64's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and congestive heart failure (CHF - decreased ability of the heart to pump blood through the body). During a resident interview on November 4, 2024, it was observed that Resident 64 appeared to have no natural teeth. A review of a physician assessment conducted on October 10, 2024, revealed the physician noted Resident 64 was edentulous (without teeth). A review of Resident 64's comprehensive plan of care revealed no dental care plan identifying that the Resident had no natural teeth. During a staff interview on November 6, 2024, at approximately 11:45 AM, the NHA confirmed that Resident 64's comprehensive plan of care did not include a care plan that addressed Resident 64's dental status of lacking natural teeth. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations, select facility meal ticket review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, during meal service, for five of 20 residents in one of one dining rooms observed (Resident's 3, 11, 27, 37, 45). Findings include: Observation of Resident 3 in the main dining room on November 3, 2024, between 11:34 AM and 11:39 AM, revealed she was sitting at a table with her food sitting in front of her not eating. Review of Resident 3's meal tickets revealed she requires full assistance with her meals; Employee 5 (Registered Nurse), was observed to sit down and start providing feeding assistance to Resident 3 at 11:39 AM. Observation in the main dining room on November 3, 2024, at 11:42 AM, revealed Resident 11 was served her meal by Employee 4 (Dietary Employee) and was sleeping. Review of Resident 11's meal tickets revealed she requires full assistance with her meals; Employee 3 (Nurse Aide), was observed to start providing feeding assistance to Resident 11 at 11:55 AM. Observation in the main dining room on November 3, 2024, between 11:37 AM and 11:57 PM, revealed Resident 27 was not eating the food she had been served. Further observation in the dining room on November 3, 2024, at 11:58 AM, revealed Employee 10 cued Resident 27 to pick up her silverware and eat her meal. Review of Resident 27's meal tickets revealed she requires supervision at meals. Review of Resident 27's clinical record revealed she has sometimes required staff to provide cueing during meals or full feeding assistance over the past fourteen days due to a noted decline. Observation in the main dining room on November 3, 2024, between 11:36 AM and 11:40 AM, revealed Resident 37's food was sitting in front of her and she was repeating What do I do? Observation of Employee 11 on November 3, 2024, at 11:40 AM, revealed she walked up to Resident 37 and stated, You have a peanut butter and jelly sandwich. Employee 11 started unwrapping Resident 37's silverware and cued her to pick up the sandwich. Review of Resident 37's meal tickets revealed she requires set-up assistance at meals. Review of Resident 37's clinical record revealed she had required oversight, encouragement, or cueing in four of the past 14 days, including that day at lunch. Observation in the main dining room on November 3, 2024, at 11:42 AM, revealed Resident 45 had been served, and was asking if someone was going to help her. During an interview with Resident 45 on November 3, 2024, at 11:44 AM, she revealed she needs help at her meals to eat. Review of Resident 45's meal tickets revealed she requires full assistance with her meals; Employee 3 (Nurse Aide), was observed to start providing feeding assistance to Resident 45 at 11:48 AM. During an interview with the Nursing Home Administrator on November 4, 2024, at 1:39 PM, she revealed her expectation that residents should be provided eating assistance, supervision, and cueing as required; and residents should not be served who require feeding assistance until nursing is ready to help them. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion receives the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one resident reviewed for range of motion services (Resident 57). Findings Include: A review of Resident 57's clinical record revealed diagnoses that included muscle weakness, abnormality of gait (a person's manner of walking), and mobility (the ability to move or be moved freely and easily). A review of the facility's policy, titled Restorative Program Standard, revised July 23, 2015, described its purpose: Nursing team members direct and provide the service with input and support from the Nursing Department/Therapy Department to increase or preserve the highest level of self-performance of residents as appropriate. Restorative Nursing is defined as nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A review of Resident 57's Occupation Therapy Discharge summary dated [DATE], revealed recommendations that included Restorative Range of Motion Program. Also, BUE [bilateral upper extremities] AROM [active range of motion] of shoulders, elbows, wrists, and fingers x 15 reps x3. A review of Resident 57's clinical record revealed no documentation of the restorative nursing program or staff implementing or providing the recommended active range of motion activities by the Occupational Therapist. An interview with the Nursing Home Administrator on November 6, 2024, at 10:39 AM, revealed the restorative nursing program was not implemented for Resident 57 upon discharge from occupational therapy on October 16, 2024, and will now be implemented by staff going forward. 28 Pa. Code 211,12 (d) (1) (2) (3) (5) Nursing services

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and one of one nourishment area. Findings include: Review of facility policy, titled Labeling and Dating of All Food Products, not dated, read, in part, Each label must contain the following information: Product name or common name or identifying description, use by date, date the product was prepared or opened, date thawed, if applicable. When a product is removed from the box the individual items must be labeled individually. Review of facility policy, titled Maximum Storage Period of Dried Goods, last revised November 2017, read, in part, Flour and spices that are opened are good for six months. Review of facility policy, titled Storage of Refrigerated & Frozen Foods, last revised November 2017, read, in part, Green onions and cut-up cooked poultry have a maximum storage period of up to 7 days, and Readycare Frozen Shakes that are thawed and unopened are good for up to 14 days. Observation of the dry storage area on November 3, 2024, at 9:37 AM, revealed: a bin of breadcrumbs labeled use by October 21, 2024; three bags of hamburger buns labeled use by October 25, 2024; one bag of hamburger buns labeled use by October 29, 2024; one bag of dinner rolls not dated; one sugar bin not labeled or dated; one flour bin labeled use by September 26, 2024; two boxes of fudge brownie mix not dated; one bag of sliced almonds open with a use by date of June 27, 2024; one bag of cane sugar labeled use by September 14, 2024; and one can of pimentos not dated. Observation in the main kitchen on November 3, 2024, at 9:50 AM, revealed one case of bananas that were black and some had started to peel open; and one container of brown sugar not labeled or dated. Observation of reach in refrigerator 1 on November 3, 2024, at 9:54 AM, revealed an individual covered side dish not labeled or dated, further observation when uncovered revealed moldy slices of cut watermelon; and one Readycare Frozen Shake that was thawed without a thawed date. Observation of the walk in refrigerator on November 3, 2024, at 9:59 AM, revealed two bags of deli turkey labeled they were sliced on September 26, 2024, and had a use by date of October 26, 2024; one contained of seafood salad labeled use by October 30, 2024; one bag of green onions not labeled with a use by date, further observation revealed most of them were dark green and wilted and were received at the facility August 21, 2024. Observation in the main kitchen on November 3, 2024, at 10:08 AM, revealed one container of whole celery seed with an open date of January 11, 2024; one open container of dill with an open date of January 16, 2024; and one open container of nutmeg with an open date of December 13, 2023; further observation of the spice rack revealed 23 containers of spices labeled with a use by date of one year from opening. Observation of the three-compartment sink in the main kitchen on November 3, 2024, at 10:29 AM, revealed Employee 2 (General Dietary Manager) tested the concentration (unit of measure) of the sanitizer water utilizing a test strip that had an expiration date of February 1, 2023. Observation of the skilled pantry area refrigerator on November 3, 2024, at 10:34 AM, revealed five Readycare Frozen Shakes that were thawed without a thawed date; nine yogurts labeled use by October 31, 2024; one container of thickened lemon water open without an open date; one container of thickened cranberry juice open without an open date; one container of thickened orange juice open without an open date; and one container of regular orange juice open without an open date. Interview with Employee 2 on November 3, 2024, at 10:41 AM, revealed the expectation of storing food and utilizing equipment considering foodservice safety and in accordance with professional standards. Interview with the Nursing Home Administrator on November 4, 2024, at 1:38 PM, 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 and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on staff interview and available documentation review, it was determined that the facility administration failed to ensure care policies were reviewed and approved by the administration and Medical Director yearly. Findings include: During an entrance staff interview on November 3, 2024, at approximately 10:20 AM, a request was made of the Nursing Home Administrator (NHA) to provide evidence that the facility's care policies had been reviewed and approved within the past year. In an electronic communication on November 5, 2024, at 2:56 PM, NHA revealed the facility was unable to locate a signatory page indicating the last care policy review date. Review of the care policy review binder that was stored near the nurses station, provided by the Director of Nursing (DON), on November 6, 2024, at approximately 9:45 AM, revealed the signatory page confirming that the NHA, DON, and Medical Director had reviewed and approved of the care policies was dated March 9, 2022. As of November 6, 2024, at 11:45 AM, the facility had no further information or evidence to provide regarding conducting a care policy review within the last year of the survey. 28 Pa code 201.18(d) Management

Based on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarters reviewed (FY Quarter 3 - April 1, 2024, to June 30, 2024). Findings include: According to Section 6106 of the Affordable Care Act (ACA), facilities are required to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered. Review State Operations Manual, under section 483.70(q), revealed Mandatory submission of staffing information based on payroll data in uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Under section 483.70(q)(4), The facility must submit direct care staffing information in the uniform format specified by CMS. Under section 483.70(q)(5), The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Review of PBJ staffing data reports for fiscal year third quarter 2024 revealed the facility triggered for Failed to Submit Data for the Quarter. During a staff interview on November 5, 2024, at approximately 10:30 AM, Nursing Home Administrator revealed the submission would have been conducted by a prior administration and was unaware if the submission to PBJ was completed or not. As of November 6, 2024, at 11:45 AM, the facility had no further information to provide. 28 Pa. Code 201.18(a) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 22 residents reviewed (Resident 12). Findings Include: Review of Resident 12's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and atrial fibrillation (A-fib- irregular heart rhythm). Review of Resident 12's annual MDS assessment (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), dated August 4, 2023, revealed that section C- Cognitive Patterns, and section D- Mood, were marked with dashes (-), meaning not assessed. During an interview with the Nursing Home Administrator, Director of Nursing, and Employee 3 on January 4, 2024, at 10:29 AM, when asked about the dashes on Resident 12's MDS assessment, Employee 3 stated that it was missed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77). Findings Include: Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. Resident 1's December 2023 physician orders included Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (MAR - documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash- medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, and the physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Review of nursing note on December 27, 2023 documented the Resident receiving Orajel for recent mouth sores. Review of Resident 1 care plan on January 2, 2023, failed to include documentation of dentures and mouth pain/ulcers. During an interview with the Director of Nursing (DON) on January 3, 2024, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures and is able to care for his dentures himself. Further review of Resident 1's care plan on January 4, 2024, documented a focus area for dental health problems due to injury related to dentures with complaint of mouth pain, initiated on January 3, 2024; with interventions that included mouth inspections as needed, report changes to nurse, and to observe/document/report to provider signs or symptoms of dental problems. During an interview with the DON on January 4, 2024, at 10:36 AM, it was revealed a dental care plan should've been initiated prior to January 3, 2024. Review of Resident 77's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD- acid reflux) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 77's current physician orders, revealed an order dated September 21, 2023, for a hospice consult evaluation and treatment. Review of Resident 77's progress notes revealed a note dated September 28, 2023, stating that Resident 77 is on hospice services as of September 28, 2023. Review of Resident 77's significant change 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), dated October 11, 2023, revealed that Resident 77 was marked as receiving hospice services. Review of Resident 77's current care plan failed to reveal a hospice care plan. On January 3, 2024, at 1:13 PM, the DON provided a hospice care plan for Resident 77 that was initiated on January 3, 2024. At that time, the DON stated that the hospice care plan should have been initiated prior to this date. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interviews, record review, and facility policy review, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for one of 19 residents reviewed (Resident 26). Findings include: Review of the facility policy, titled Comprehensive Care Plan Standard, last reviewed July 2023, revealed that it requires the resident's care plan to be reviewed and revised, if applicable, by the interdisciplinary team after each annual and quarterly assessment. Review of Resident 26's clinical record on January 2, 2024, revealed diagnoses that include diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hypertension (elevated blood pressure). Review of the current care plan on January 3, 2024, at 10:30 AM, revealed a care plan for pain related to lower left leg cellulitis (bacterial skin infection). Resident 26 was admitted with a diagnosis of cellulitis on July 2, 2022, and the cellulitis was resolved after treatment with antibiotics. The cellulitis was never removed from the care plan. During an interview with the Nursing Home Administrator and Clinical Consultant on January 4, 2024, at 10:30 AM, both were in agreement that the care plan should have been revised to remove the cellulitis diagnosis. 28 Pa. Code 211.12(d)(1)(3)Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Dental Services policy, observations, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 22 residents reviewed (Resident 1). Findings: Review of the facility's Dental Services policy, revised November 28, 2017, read, in part, the facility must assist residents in obtaining routine and emergency dental care. Routine services include an annual inspection of the oral cavity including fitting dentures. Emergency dental services includes treatment of acute pain of teeth or gums by a dentist. Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. The Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, revealed Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. On January 2, 2024, review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], payor source as of October 14, 2023, was Community Heath Choices AmeriHealth caritas (Pennsylvania medical assistance managed care health plan), and was cognitively intact per Brief Interview For Mental Status (BIMS- a test to evaluate cognition) score of 14, completed on December 28, 2023. Resident 1's December 2023 physician orders included: consult podiatry, vision, dental and audiology services as ordered (360Care Podiatry, vision, dental), start date February 3, 2023; and Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash - medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Review of nursing note on December 27, 2023, documented the Resident receiving Orajel for recent mouth sores. During an interview with the Nursing Home Administrator (NHA) on January 3, 2024, at 11:10 AM, it was revealed that, per 360Care, prepayment is needed before scheduling an appointment. During an interview with the Director of Nursing (DON) on January 3, 2023, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures, and is able to care for his dentures himself. It was also revealed that the physician followed-up with Resident 1 regarding his pain in his lower jaw. DON stated that there wasn't a white patch on Resident 1's lower jaw. DON reiterated that the facility provided information stating 360Care required prepayment before scheduling an appointment. Resident 1's lower gum line slightly erythematous with no open area. Recommendation made to keep lower denture out between meals, continue use of Orajel and follow-up with dentist to evaluate need for new dentures. this seems out of place or needs more info? Interview with Corporate Nurse on January 3, 2024, at 2:40 PM, revealed that, with the new contract, 360Care does require prepayment for residents who are Medicaid pending. Census documentation revealed Resident 1 was Medicaid pending September 16, 2022, through December 21, 2022, then was on skilled services October 22, 2022, through October 13, 2023, and was on Medicaid services as of October 14, 2023. During an interview with NHA on January 3, 2024, at 2:40 PM, it was revealed that he wasn't aware that Resident 1 was in emergent need to see a dentist. Resident 1 is able to eat and has not lost weight. Resident 1's family opted for dental services to be on hold until Resident 1 was on Medicaid. The dentist requires prepayment for services for certain payor sources. During an interview with the DON and Employee 7 (Unit Manager) on January 4, 2024, at 11:20 AM, it was revealed that Resident 1 wasn't on Medicaid until October 14, 2023, the family wasn't willing to prepay for routine dental services, and the family opted to wait until Resident 1 was on Medicaid services. It was also revealed that dental pain would not be considered need for emergent dental services, and the physician was managing and monitoring Resident's dental health. It was confirmed that the dentist is expected in the facility March 2024, the dental office should be aware that Resident 1's payor source was Medicaid, and should be scheduled for a routine dental visit; however, they weren't able to confirm that Resident 1 was on the dentist schedule to be seen March 2024. During the interview with DON and Employee 7 on January 4, 2024, at 12:00 PM, revealed Resident 1 was not seen for routine dental due to having dentures without concerns and not being active on Medicaid. It was also revealed that Resident 1 is scheduled to be seen by the facility dentist on February 28, 2024, at 9:00 AM. The facility failed to provide routine and emergent dental services in a timely manner as evidence by treatment for dental pain initiated December 1, 2023, with additional intervention December 11, 2023. Further, the facility failed to evaluate/monitor Resident 1's oral health and dental pain prior to surveyor questioning Resident 1's oral pain and, at that point, the physician did complete a follow-up visit on January 3, 2024, recommending Resident 1 be seen by a dentist. 28 Pa Code 211.15 Dental services

Based on clinical record review, observation, and interviews, it was determined that the facility failed to ensure that a resident with pressure ulcers received care consistent with professional standards of practice for one of two Residents reviewed (Resident 13). Findings include: A review of the clinical record for Resident 13 on January 17, 2023, revealed clinical diagnoses that included type II diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and absence of right leg below the knee (amputation). A review of Resident 13's current physician orders dated January 2023, includes wound care every Tuesday, Thursday, and Saturday to pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the left buttock, sacrum (area below lumbar region), right ischium (skin around posterior pelvic rim), and surgical wound left upper back. Observation of wound care by Employee 3 (Licensed Practical Nurse [LPN]) and assisted by Employee 1 (Registered Nurse) on January 17, 2023, at 1:15 PM, revealed four wound dressings without any date or initials to specify when the dressings were last changed. The dressing were located on the left buttock, left back, sacrum, and right ischium. During an interview with the Employee 1 (Registered Nurse) on January 17, 2023, she stated, is it good enough that staff sign off on the treatment administration record? On January 17, 2023, at approximately 1:45 PM, the facility was requested to provide a wound care policy that addressed the standards of practice during wound care procedure. The facility was unable to provide a specific policy that addressed the standards of practice during wound care. The facility was able to provide a form, titled Wound and Skin Guidelines, last reviewed October 2019. These guidelines provided treatment type based on skin tears, abrasions, pressure ulcers, and peri-wounds (area around a wound) only specifying type of dressing and frequency to change the dressing. During an interview with Employee 1 on January 18, 2023, at 11:10 AM, Employee 1 informed the surveyor the facility follows Lippincott's Nursing standard of practice and agreed the wound dressings should be dated and labeled based on standards of practice. Lippincott's wound procedure states, after securing the dressing, label dressing with date and time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory services for one of 24 residents reviewed (Resident 66). Findings include: Review of facility provided policy, titled Oxygen Administration, dated 2006, revealed that employees should label the humidification bottle of water with the date and time it was opened. The same policy failed to reveal whether oxygen tubing should be labeled. Review of Resident 66's clinical record revealed diagnoses that include diabetes mellitus (a group of diseases that result in too much sugar in the blood (high blood glucose)) and Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Observation of Resident 66 on January 17, 2023, at 10:22 AM, revealed the Resident sitting in their wheelchair. Behind the wheelchair was an oxygen concentrator with oxygen/nasal canula tubing, with label noting that it was put into use on January 9, 2023, and a humidification bottle of water with label noting that it was put into use on January 8, 2023. Observation of Resident 66 on January 18, 2023, at 11:55 AM, revealed the Resident sitting in their wheelchair. Behind the wheelchair was an oxygen concentrator with oxygen/nasal canula tubing, with label noting that it was put into use on January 9, 2023, and a humidification bottle of water with label noting that it was put into use on January 8, 2023. Review of Resident 66's current care plan on January 18, 2023, revealed a care plan of I am at risk for complication as I have oxygen therapy with an intervention of OXYGEN Settings: I use oxygen via nasal canula per MD (medical doctor) orders, with a revision date of July 23, 2021. Review of Resident 66's current physician orders on January 18, 2023, revealed a current physician's order for Resident 66 to receive supplemental oxygen via nasal canula at bedtime and as needed. Further review of Resident 66's current physician orders revealed a current physician's order to change and date the O2 equipment (tubing and humidifier bottle) and clean the concentrator filter every week every night shift every Sunday. Review of Resident 66's Medication Administration Record/Treatment Administration Record (MAR/TAR) for January 2023, reviewed on January 18, 2023, revealed that an employee had indicated that they changed the oxygen tubing and humidification bottle on January 15, 2023, (even though it had not been changed). Interview with the Nursing Home Administrator on January 19, 2023, at 10:35 AM, revealed that he had gone and looked at the tubing, it was indeed not changed on January 15, 2023, as ordered. He stated that the facility nurses had then initiated an audit of all oxygen tubing and humidification bottles being used by residents to ensure they were all changed in accordance with facility policy and physician orders. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure pharmacist recommended irregularities are reviewed and acted upon by the attending physician for two of 22 residents reviewed (Residents 67 and 84). Findings Include: Review of facility policy titled Admission/readmission Drug Regimen Review/Medication Reconciliation Standard (DRR), effective October 1, 2018, failed to reveal any expectation for the physician to review and respond to recommendations made by the pharmacy. Review of Resident 67's clinical record revealed diagnoses that included gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)) and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 67's progress notes revealed a that medication regimen review was completed on November 29, 2022, with irregularities noted that would need reviewed by the physician. Review of facility provided documents failed to reveal any evidence that a physician reviewed or responded to the recommendations made by the consultant pharmacist on November 29, 2022. Interview with the Employee 1 (Clinical Excellence Nurse) on January 18, 2022, at 1:30 PM, revealed that the physician did not respond to Resident 67's medication regiment review from November 29, 2022. Review of Resident 84's clinical record revealed diagnoses that included dementia ( a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Review of Resident 84's interdisciplinary progress notes revealed a pharmacist visit and medication review dated November 29, 2022. Review of the pharmacist document titled Note to Attending Physician/Prescriber revealed a recommendation to the physician regarding Resident 84's prescribed medication Quetiapine (an antipsychotic medication) 25 mg (milligrams) that should be considered for a gradual dose reduction based on medical standards. Continued review of the document revealed the physician had not responded to the recommendation for the consideration of a gradual dose reduction of the medication. An interview with the Employee 1, on January 18, 2023, at 12:29 PM, confirmed the recommendation was not reviewed or acted upon by Resident 84's physician. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: During interview with the Nursing Home Administrator (NHA) on January 19, 2023, at 9:30 AM, the facility was unable to provide a policy that addressed water management or a list of water management team members. During the interview with the NHA on January 19, 2023, additional data was requested and unable to be provided that would support implementation of a water management program, such as legionella risk assessment, a water system flow chart that identifies risk areas, testing of shower heads, and professional water testing to determine any contaminants. The facility was unable to show control measures to prevent growth and spread of water-borne contaminants, no water quality parameter measurements, no validation for routine environmental sample results of Legionella testing, no monitoring of high risk areas, and no plan for when control limits are not met and/or control measures are not effective. During an interview with Employee 5 (Director of Building and Grounds) on January 19, 2023, at approximately 11:30 AM, Employee 5 was unaware of the requirement to develop a water management program. During a final interview with the NHA on January 19, 2023, at 11:45AM, the NHA confirmed the facility hasn't developed a water management program. 28 Pa. Code 201.18(b)(1)(d)(e)(1)Management