Gardens At East Mountain, The

F-F657

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.16 (a) Social Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142

Residents Affected - Some Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure the provision of pharmacy services to assure the timely receipt and administration of physician-prescribed medications for three (3) of twenty-one (21) residents reviewed (Residents 90, 64, and 201). The facility also failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system.

Findings include:

Review of clinical record revealed that Resident 90, was admitted to the facility on [DATE REDACTED], at 10:45 AM with diagnoses to include chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing), depression, and anxiety.

A physician order dated February 4, 2025, documented an order for Clonazepam (an antianxiety medication) 1 mg by mouth twice daily for a diagnosis of anxiety.

A review of the February 2025 Medication Administration Record (MAR) revealed that Clonazepam was not administered to Resident 90 as prescribed on February 4, 2025, due to awaiting pharmacy delivery. An

interview with the Director of Nursing (DON) on March 5, 2025, at approximately 11:00 AM confirmed that

the medication was not available in the facility due to a delay in pharmacy delivery.

Review of the clinical record revealed Resident 64 was admitted to the facility on [DATE REDACTED] with diagnosis to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues).

The resident sustained a fall on February 23, 2025, at 9:30 PM and was hospitalized with fractures of the right hip and right pubic ramus. Upon readmission to the facility on [DATE REDACTED], at 3:00 PM the resident had physician orders for Oxycodone HCL 5 mg every 4 hours (a narcotic opioid pain medication) for moderate pain as needed, hospital documentation, The resident received 2 doses of oxycodone in the hospital, one at 5:57 AM and another at 10:19 AM.

A review of the facility physician orders dated February 24, 2025, at 9:00 PM revealed an order for Oxycodone HCL 5 mg by mouth every 4 hours as needed for pain rated 6-10 on the pain scale. However,

this order was discontinued on February 25, 2025, at 7:00 AM. A new order for Oxycodone HCL 5 mg every 4 hours as needed for pain was re-entered on February 25, 2025, at 7:00 AM, with the addition of non-pharmacological interventions.

A review of Resident 64's February 2025 Medication Administration Record (MAR) indicated that the resident did not receive Oxycodone on February 24, 2025, February 25, 2025, February 26, 2025, or February 27, 2025. The first recorded administration of Oxycodone was at 7:09 AM on February 27, 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Nursing documentation dated February 27, 2025, at 6:09 AM noted that the resident exhibited increased confusion throughout the night, reporting visual hallucinations of children in her room. She remained awake Level of Harm - Minimal harm or all night and was unable to be redirected or oriented to time and place. The documentation further stated that potential for actual harm she complained of pain and was given Tylenol instead of Oxycodone. A note was placed on the provider's communication board requesting a signed prescription for Oxycodone HCL 5 mg. The documentation also Residents Affected - Some indicated that the medication had not been available in the facility since the resident's hospital discharge.

A review of the clinical record confirmed that the medication was not administered due to a delay in delivery from the pharmacy.

An interview with the Director of Nursing (DON) on March 5, 2025, at 2:15 PM revealed that the facility's procedure when a medication is unavailable from the pharmacy is to check the emergency supply to determine if the medication is available. If the medication is not available, the physician should be consulted for further instruction.

A review of the facility's emergency medication supply confirmed that Oxycodone HCL 5 mg was not available in the emergency cart.

Clinical record review revealed that Resident 201 was admitted to the facility on [DATE REDACTED], with diagnoses to include aftercare and therapy after hospitalization , muscle weakness and atrial fibrillation (an irregular heartbeat reducing the heart's ability to pump blood through the body reducing oxygen supply).

Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 17, 2024, indicated

the resident had a BIMS (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 15 indicating he was cognitively intact.

Review of Resident 201's January 2025 Medication Administration Record revealed Physician orders to include:

Diltiazem HCl ER 300 mg daily for hypertension

Oxycodone-Acetaminophen 5-325 mg every 6 hours as needed for moderate pain

Levothyroxine Sodium 88 mcg daily for thyroid management.

A review of the January 2025 MAR (medication administration record) revealed that Diltiazem HCl ER, Oxycodone-Acetaminophen, and Levothyroxine Sodium were not administered on January 15, 2025, due to pharmacy delays, and were not available until January 16, 2025. The DON confirmed on March 5, 2025, that

the medications were unavailable and not stocked in the emergency supply

A review of facility pharmacy policy reviewed January 16, 2025, entitled, Emergency Medication System: Removal of Outdated Medications revealed, the contract pharmacy staff shall perform routine audits of the system to ensure the integrity of contents and outdated or soon to be outdated contents are removed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Procedures to include, Audits shall be performed routinely to ensure the OOS (Pyxis like system, an automated, medication system, located in the facility) do not contain outdated medications. Medications Level of Harm - Minimal harm or should be removed at least 90 days prior to expiration. Non-controlled medications may be returned potential for actual harm outdated/excess medications to the pharmacy. Non-controlled medications may be returned to the pharmacy by courier during the daily medication delivery return process. A list of medications removed shall be created Residents Affected - Some and signed by both the pharmacy staff and the nursing staff. A list of each item and quantity shall be provided to the facility.

A review of the facility's emergency medication supply and observation of the automated medication dispensing system on March 7, 2025, at 12:00 PM, revealed discrepancies between the recorded medication inventory and the actual stock. The noted medication's expiration dates in the system did not match the actual expiration dates on the unit dose packs of the meds contained in the machine and medications listed as available were not physically present.

The facility failed to provide documentation of pharmacy oversight, including routine monthly audits for expired medications and medication availability.

A review of the facility's Medication Ordering and Receipt, After-Hours Pharmacy Service policy revealed that emergency pharmaceutical services are available 24 hours a day, 365 days a year. According to the policy, emergency medication needs should be met using onsite supplies provided by the pharmacy, including an emergency box, interim box, starter kit, controlled substance interim box, and an electronic cabinet, as permitted by regulations. The policy further states that STAT (immediate) medication requests can be made to the pharmacy and that a corporate pharmacist is available 24/7 to either dispense medications from the pharmacy or arrange for dispensing from a backup pharmacy to meet the facility's medication needs.

However, during an interview on March 7, 2025, at 11:00 AM the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility did not have a backup emergency pharmacy, despite the policy stating that one should be available. They stated the facility relied solely on an out of state-based pharmacy with daily courier deliveries. Additionally, they acknowledged that facility nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated medication dispensing system.

The DON further confirmed that facility staff had not received training from a pharmacist on proper restocking procedures and that no documentation of pharmacy oversight or staff training was provided during the survey.

The facility failed to provide timely access to physician-prescribed medications for multiple residents, resulting in delays in the administration of essential medications, including pain management and critical daily prescriptions. Additionally, the facility lacked a process to ensure emergency medication availability and failed to maintain proper oversight of the medication dispensing system.

28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277 potential for actual harm Based on review of clinical records and resident payor source data, and staff interview, it was determined the Residents Affected - Few facility failed to offer routine annual dental services for two private payor source residents (Residents 60 and 39) out of four residents sampled for dental services.

Findings include:

Review of Resident 60's clinical record revealed admission to the facility on [DATE REDACTED], with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) and COPD (chronic obstructive pulmonary disease-lung disease that blocks airflow and makes it difficult to breathe). The resident was identified as private payor source.

Review of Resident 60's quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated February 9, 2025, indicated that

the resident was severely cognitively impaired.

There was no documented evidence in the clinical record at the time of the survey ending March 7, 2025, that Resident 60's responsible party was offered routine annual dental services for Resident 60 in the past year.

Review of Resident 39's clinical record revealed admission to the facility on [DATE REDACTED], with diagnosis to include Alzheimer's disease and muscle weakness. The resident was identified as private payor source.

There was no documented evidence in the clinical record at the time of the survey ending March 7, 2025, that Resident 39's responsible party was offered routine annual dental services for Resident 60 in the past year.

Interview with the Director of Nursing on March 6, 2025, at 9:15 AM confirmed that Resdient 60 and 39's resident's responsible party had not been consulted regarding offering of dental services in the past year.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48277 potential for actual harm Based on review of clinical records and resident payor source data, and staff interview, it was determined the Residents Affected - Few facility failed to offer routine annual dental services for one Medicaid payor source resident (Resident 64) out of four residents sampled for dental services.

Findings include:

Review of Resident 64's clinical record revealed admission to the facility on [DATE REDACTED] with diagnosis to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). The resident was identified as Medicaid payor source.

Review of Resident 64's Annual Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated November 18, 2024, indicated that the resident was moderately cognitively impaired.

There was no documented evidence in the clinical record at the time of the survey ending March 7, 2025, that Resident 64's responsible party was offered routine annual dental services for Resident 64 in the past year.

Interview with the Director of Nursing on March 6, 2025, at 9:15 AM confirmed that the resident's responsible party had not been consulted regarding the offering of dental services for Resident 64 in the past year.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm 26142 Residents Affected - Some Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49.

Findings include:

A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code S 27.204 - Automated medication systems revealed:

(a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions.

(b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that:

(1) The pharmacist manager, or the pharmacist under contract with a

long-term care facility responsible for the dispensing of medications if an automated medication system is utilized at a location which does not have a pharmacy onsite, is responsible for the supervision of the operation of the system.

(4) The automated medication system must electronically record the activity of each pharmacist, technician or other authorized personnel with the time, date and initials or other identifier so that a clear, readily retrievable audit trail is established. A pharmacist will be held responsible for transactions performed by that pharmacist or under the supervision of that pharmacist.

(c) The pharmacist manager or the pharmacist under contract with a long-term care facility responsible for

the delivery of medications shall be responsible for the following

(2) Ensuring that medications in the automated medication system are inspected, at least monthly, for expiration date, misbranding and physical integrity, and ensuring that the automated medication system is inspected, at least monthly, for security and accountability.

(4) Ensuring that the automated medication system is stocked accurately, and an accountability record is maintained in accordance with the written policies and procedures of operation.

(5) Ensuring compliance with the applicable provisions of State and Federal law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 (6) Set forth methods that ensure that access to the automated medication system for stocking and removal of medications is limited to licensed pharmacists or the pharmacist's designee acting under the supervision Level of Harm - Minimal harm or of a licensed pharmacist. An accountability record which documents all transactions relative to stocking and potential for actual harm removing medications from the automated medication system must be maintained.

Residents Affected - Some (g) The pharmacist manager shall be responsible for ensuring that, prior to performing any services in connection with an automated medication system, all licensed practitioners and supportive personnel are trained in the

pharmacy's standard operating procedures with regard to automated medication systems set forth in the written policies and procedures. The training shall be documented and available for inspection.

Specifically, the facility failed to ensure:

The oversight and management of the automated medication system as required by Pennsylvania Code Title 49, Chapter 27, which mandates pharmacist supervision, system inspections, and proper medication accountability.

The timely delivery and availability of prescribed medications, leading to multiple instances of missed doses for residents, including Clonazepam for Resident 90, Oxycodone for Resident 64, and Diltiazem, Levothyroxine, and Oxycodone-Acetaminophen for Resident 201.

The maintenance of a readily retrievable audit trail and documented oversight of the automated medication system. The Pennsylvania code Title 49 require that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications. However, the facility failed to provide documentation verifying that the required oversight and management of the automated medication system were conducted.

During an interview on March 7, 2025, at 11:00 AM, the Nursing Home Administrator confirmed the facility pharmacy did not adhere to the Pennsylvania code regarding pharmacy services. She further stated that documentation regarding oversight of the system was unavailable, and that pharmacy staff were not actively managing the system. This lack of oversight contributed to medication availability issues, delays in administration, and a failure to maintain regulatory compliance.

Cross refer

F-F755

28 Pa. Code 201.18 (b)(3)(e)(1)Management.

28 Pa. Code 211.9 (a)(l)(d)(k)(l)(1)(2)(3) Pharmacy Services.

28 Pa. Code 211.12 (d)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 395706 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395706 B. Wing 03/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of East Mountain 101 East Mountain Drive Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142

Residents Affected - Few Based on clinical record review, and staff interview, it was determined the facility failed to ensure coordination of Hospice services with facility services to meet each individual residents' needs daily for the management of a terminal illness of one of two residents reviewed receiving hospice services. (Resident 54 and 61).

Findings include:

A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE REDACTED], with diagnoses of cerebral infarct (stroke). The resident was admitted to hospice services on February 5, 2025, for cerebral infarct.

Review of Resident 54's plan of care, during the survey ending March 7, 2025, revealed no evidence the resident's plan of care was integrated with hospice services to demonstrate coordination of care and services to meet the resident's needs related to the care of the resident's terminal illness daily.

A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE REDACTED], with diagnoses of dementia, chronic obstructive pulmonary disease (a progressive lung disease) and anxiety.

The resident was admitted to hospice services on October 10, 2024, for end stage chronic obstructive pulmonary disease.

Review of Resident 61's plan of care, during the survey ending March 7, 2025, revealed the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis.

There was no evidence the hospice and the nursing home collaborated in the development of a coordinated plan of care for each resident receiving hospice services to identify the provider responsible for performing each or any specific services/functions that have been agreed upon and the location of the necessary plans.

During interview with the Director of Nursing (DON) on March 6, 2025, at 2:00PM she confirmed the residents' care plans were not integrated/coordinated with hospice for Resident 54 and 61.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 395706