Every finding on record at Acadia Nursing and Rehab Center

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, failed to properly maintain the dishwater temperature logs, failed to maintain kitchen equipment in a sanitary condition, failed to properly store chemicals, and failed to properly restrain hair creating the potential for cross contamination in the Main Kitchen of the facility and the facility failed to ensure food was stored and maintained in accordance with professional standards for food safety for one of two resident refrigerators (Conference Room - Resident Refrigerator).Findings include: Review of the facility policy Food Receiving and Storage last reviewed 4/30/26, indicated foods shall be received and stored in a manner that complies with safe food handling practices. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Refrigerated foods are labeled dated and monitored. Review of the facility policy Poisonous and toxic Materials last reviewed 4/30/26, indicated all containers and toxic materials that are required to maintain kitchen sanitization shall be permitted in the pot washing and dishwashing areas. But may not be stored or used in the presence of food. Review of the facility policy Preventing Foodborne illness- Employee Hygiene and Sanitary Practices last reviewed 4/30/26, indicated hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contracting exposed food, clean equipment, utensils and linens. Review of the facility policy Refrigerators and Freezers last reviewed 4/30/26, indicated this facility will ensure safe refrigeration and freezer maintenance, temperatures and sanitization and will observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. All food is appropriately dated to ensure proper rotation by expiration dates. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solutions on a scheduled basis and more often as necessary. Review of the facility policy Foods Brought by Families/Visitors last reviewed 4/30/26, indicated home prepared and home-preserved foods are permitted if brought in by family or visitors for individual residents. Potentially hazardous foods that are left out for the residents without a source of heat or refrigeration longer than two hours will be discarded. Perishable foods must be stored in re-sealable containers and must be labeled with the resident's name, the food item and the use by date. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger. Observation on 6/7/27, of a posting on the conference room resident refrigerator that stated any food or drinks left in the refrigerator without a date and name will be discarded daily. Any food left here with a date will also be discarded after three days. During an observation completed on 6/7/26, at 9:15 a.m. the dry storage room contained:A bag of Lays Potato chips opened and not labeled with a date as required.A Bag of [NAME] Noodles opened and not labeled with a date as required.A Bag Sysco spiral noodles opened and not labeled with a date as required.A bag of [NAME] Penne noodles opened and not labeled with a date as required.A bag of [NAME] spaghetti noodles opened and not labeled with a date as required.A bag of stuffing mix of stuffing mix opened and not labeled with a date as required.A Bottle of Mrs. Butterworths syrup opened and not labeled with a date as required.During an interview completed on 6/7/26 at 9:18 a.m. Dietary Aide Employee E14 confirmed the above observations and that the facility failed to properly label and date food products in the dry storage area. During an observation completed on 6/7/26, at 9:20 a.m. the Dishwater temperature log was incomplete for the following dates:6/5/26, no temperatures logged for lunch or dinner6/6/26, no temperatures logged for breakfast or lunchDuring an interview completed on 6/7/26, at 9:21 a.m. Dietary Aide Employee E14 confirmed the facility failed to properly maintain the dishwater temperature logs. During an observation completed on 6/7/26, at 9:27 a.m. the walk-in freezer contained:A box of rolls opened and not labeled with a date as required.A box of hash browns opened and not labeled with a date as required.A box of hotdog buns opened and not labeled with a date as required the top of the box appeared to have water damage and had ice buildup.A box of hamburger buns opened and not labeled with a date as required, the top of the box appeared to have water damage and had ice buildup.The freezer fan above the hotdog and hamburger buns had a fuzzy substance on it.During an interview completed on 6/7/26, at 9:30 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to properly label and date food products and failed to maintain kitchen equipment in a sanitary condition for the walk-in freezer. During an observation of walk-in cooler #2 the following was observed:The shelves on the right side were covered in a rust-like substanceA box of hotdog buns opened and not labeled with a date as required.A jar of grape jelly opened and not labeled with a date as required.A jar of pickled relish opened and not labeled with a date as required.A pan of cornbread partially served, covered with saran wrap not labeled with a date as required.During an interview completed on 6/7/26, at 9:32 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to properly label and date food products, and failed to maintain kitchen equipment in a sanitary condition, During an observation completed on 6/7/26, at 9:35 a.m. the following was discovered outside of cooler #2A clear plastic container of flour with loose flour and grime on top of the lid.A clear plastic container with sugar with grime on top of the lid.A clear plastic container with salt container with grime on the top of lid. During an interview completed on 6/7/26, at 9:36 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to maintain kitchen equipment in a sanitary condition. During an observation completed on 6/7/26, at 9:38 a.m. the stove top grills oven doors was covered in a brownish-black grimy substance. During an interview completed on 6/7/26, at 9:40 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to maintain kitchen equipment in a sanitary condition. During an observation completed on 6/7/26, at 9:41 a.m. an extra cart was parked next to the stove and contained:A bag of mashed potatoes opened and not labeled with a date as required.A plastic jar of grape Kool-Aid opened and not labeled with a date as required.A container of Sani-wipesDuring an interview completed on 6/7/26, at 9:43 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to properly label and date food products and failed to properly store chemical products. During an observation completed on 6/7/26, at 9:44 a.m. the table in the center of the kitchen contained:A stack of hot plate lids not invertedA container of pepper opened and not labeled with a date as required.A container of salt opened and not labeled with a date as required. 2 carts parked next to the table had stacks of hot plate lids not inverted. During an interview completed on 6/7/26, at 9:45 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to properly label and date food products and failed to maintain kitchen equipment in a sanitary condition. During an observation completed on 6/7/26, at 9:47 a.m. the kitchen standing cooler contained:A tray of sliced tomatoes with the use by date of 5/30/26.A jar of mayonnaise opened and not labeled with a date as required.A package of hamburger buns opened and not labeled with a date as required.A loaf of bread opened and not labeled with a date as required.A bag of shredded Monterey jack cheeses opened and not labeled with a date as required.A container of liquid eggs opened and not labeled with a date as required.A package of sliced lunch-meat ham opened and not labeled with a date as required. During an interview completed on 6/7/26, at 9:50 a.m. Dietary [NAME] Employee E13 confirmed the above observations and that the facility failed to properly label and date food products. During the observation of the main kitchen on 6/7/26, Dietary [NAME] Employee E13 and Dietary Aide E12 did not have beard coverings on. During an observation of the kitchen on 6/8/26, at 12:00 p.m. Dietary [NAME] Employee E13, Dietary Aide E12 and Dietary Aid E10 were in the kitchen preparing for lunch without beard coverings. During an interview completed on 6/8/26, at 12:23 p.m. Dietary Manager Employee E12 confirmed the employees in the kitchen preparing for lunch were without beard coverings and the facility failed to properly restrain hair creating the potential for cross contamination. During an observation completed on 6/8/26, at 1:20 p.m. the conference room resident refrigerator contained the following:4 peanut butter and jelly sandwiches.A container of chicken noodle soup dated 5/10/26.A pizza box containing 3 slices of pizza not labeled with the resident's name or date.A 1/2 gallon jug of orange juice with the use by date of 6/1/26.2 small containers of chocolate milk with the expiration date of 5/29/26.1 small container of whole milk with the expiration date of 6/2/26.A bag of sliced Cantaloupe with the date of 6/1/26.2 bottles of Catalina salad dressing2 bottles of Catalina salad dressing no date opened and not labeled with a date as required.A bottle of ketchup opened and not labeled with a date as required.The freezer section of the conference room refrigerator contained:1 blue ice pack2 white ice packs During an interview completed on 6/8/26, at 1:25 p.m. Licensed Practical Nurse Employee E 2 confirmed the above observations and that the facility failed to ensure food was stored and maintained in accordance with professional standards for food safety for one of two resident refrigerators (Conference Room - Resident Refrigerator). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (R5, R17, and R45). Findings include: Review of the facility policy Departmental (Respiratory Therapy) Prevention of Infection dated 4/30/26, indicated that the oxygen cannula (thin flexible tubing used to deliver oxygen) and tubing are changed every seven days. Review of the admission record indicated Resident R5 admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R5's physician order dated 3/26/26, indicated Albuterol Sulfate Inhalation Nebulization Solution (delivers medicine directly into the lungs to treat respiratory diseases) three milliliters inhale orally every four hours as needed for shortness of breath and wheezing. Observation on 6/7/26, at 8:48 a.m. Resident R5 was observed out of bed in a wheelchair with a nebulizer machine on the bedside stand. The nebulizer was not labeled with a date and time last changed. Review of the admission record indicated Resident R17 admitted to the facility on [DATE]. Review of Resident R17's MDS dated [DATE], indicated the diagnoses of heart failure, high blood pressure, and anxiety. Review of Resident R17's current physician orders indicated change oxygen tubing and bottle weekly and as needed. Initial tubing and bottle at time of change. Place tubing in dated plastic bag when not in use. Observation on 6/7/26, at 9:00 a.m. Resident R17 was observed lying in bed with a nasal cannula in the nose connected to an oxygen concentrator. The cannula was not labeled with a date and time last changed. Observation and interview on 6/7/26, at 9:05 a.m. with Licensed Practical Nurse (LPN) Employee E2 confirmed Resident R17's cannula was not labeled with a date and time last changed as required. Review of the admission record indicated Resident R45 admitted to the facility on [DATE]. Review of Resident R45's MDS dated [DATE], indicated the diagnoses of high blood pressure, depression, and anxiety. Review of Resident R45's current physician orders indicated change oxygen tubing and bottle weekly and as needed. Initial tubing and bottle at time of change. Place tubing in dated plastic bag when not in use. Observation on 6/7/26, at 9:07 a.m. Resident R45 was observed in bed, a portable oxygen tank was on the back of the wheelchair with an oxygen cannula, not dated and not bagged, dangling on the seat of the wheelchair. Observation and interview on 6/7/26, at 9:09 a.m. with Registered Nurse (RN) Employee E1 confirmed Resident R5's nebulizer and Resident R45's oxygen cannula were not labeled with a date and time last changed as required. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Based on review of clinical records and staff interview, it was determined that the facility provider failed to notify a resident of planned changes to resident's medications and failed to allow the resident to be able to participate in the decision-making process regarding resident's care for one of three residents (Resident R68).Findings include: Review of the facility policy Resident Rights dated [DATE], indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include resident's right to: be notified of his or her medical condition and of any changes in his or her condition. Be informed of, and participate in his or her care planning and treatment. Choose an attending physician and participate in decision-making regarding his or her care. Review of the clinical record revealed Resident R68 was admitted to the facility on [DATE], with diagnoses of urinary tract infection, seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), anxiety (intense, excessive, and persistent worry and fear about everyday situations), bulimia nervosa (a type of eating disorder), borderline personality disorder (a mental health condition characterized by profound emotional instability). Review of resident R68's care plan dated [DATE], indicated:-Episodes of anxiety related to disease process anxiety/depression/schizophrenia. -Potential to exhibit behaviors that are a result of past trauma(s), which may impactmy moods or behaviors as evidence by a negative mood, avoidance symptoms and/or intrusion symptoms. Past and/or current drug abuse/sexual assault.- Offer choices to enhance sense of control.-Resistive/noncompliant with treatment and care related to Bulimia, PTSD, and borderline personality disorder. Ask physician to explain/reinforce need for treatment. Review of Resident R68's hospital records dated [DATE], indicated resident was to continue clonazepam (medication to treat seizures and treat panic disorders) 0.5 mg (milligram) tablet two tablets at bedtime as needed for anxiety. Review of Resident R68's physician orders dated [DATE], indicated Clonazepam Tablet 0.5 MG Give two tablets by mouth as needed for anxiety related to anxiety disorder for 14 days at bedtime. Review of Resident R68's physician orders dated [DATE], indicated Ativan (antianxiety medication)Injection Solution 2 MG/ML inject 0.5 milliliter intramuscularly (in the muscle layer) as needed for Anxiety 1mg up to three times per day as needed for anxiety. Review of physician visit progress note dated [DATE], at 11:19 p.m. Indicated Resident was seen today as a new patient. Assessment and plan: Resident will be admitted . We will continue resident's medications for resident's chronic medical issues and follow up with resident's specialists as scheduled. We will see resident on a routine basis or sooner if needed. Review of Nurse Practitioner (NP) Employee E20's late entry dated [DATE], at 12:36 p.m. indicated resident is seen today for a routine visit. Assessment and plan: we will continue her medications for resident's chronic medical issues and follow up with the resident's specialists as scheduled. Will discontinue evening clonazepam and intramuscular (IM) Ativan. Increase oral as needed Ativan to 1mg. The note of the visit did not include documentation that Resident R68 was informed of the medication changes planned and able to participate in the decision-making process regarding resident's care. Review of progress note dated [DATE], at 7:11 a.m. indicated at approximately 5:00 a.m. resident indicated they had a bad dream and were starting to feel anxious. Resident asked for something for anxiety. Upon review this nurse noted that resident was given bedtime Clonazepam as well as trazadone by this nurse. Although resident had order for intramuscular Ativan the medication was not available at that time due to previous order having expired and a new order required a new script. Review of progress note dated [DATE], at 1:42 p.m. indicated notified physician of need for script renewal for Ativan injection. Physician reviewed resident's medications. Per physician, resident on too many benzodiazepines and medications need adjusted. Orders received to discontinue Clonazepam 0.5 mg tablet as needed and Ativan IM injection as needed. New order for Ativan 1 mg tablet every eight hours as needed for anxiety and seizures. Orders discontinued and placed. Notified resident of medication change, and resident began crying loudly stating, I hate it here! Nobody listens to me! Why would the doctor take my medication away without talking to me first! How am I supposed to sleep? RN supervisor informed the resident that they will still receive Ativan every eight hours as needed for anxiety or seizure activity. Resident was unable to be consoled. Resident's family notified of medication changes and resident's reaction to medication changes. Review of progress note dated [DATE], at 5:38 a.m. indicated resident discharged Against Medical Advice and left the facility in the family vehicle with resident's family. Interview on [DATE], at 2:00 p.m. the Director of Nursing confirmed that the facility provider failed to notify a resident of planned changes to resident's medications and failed to allow the resident to be able to participate in the decision-making process regarding resident's care for one of three residents (Resident R68). 28 Pa. Code: 211.12(d)(1) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain a confidential personal medical record for one of two residents (Resident R20).Findings include: A review of the facility policy titled, Resident Rights last reviewed 4/30/26, indicated that federal and state law guarantee certain basic rights to all residents in the facility these include but not inclusive to:A dignified experienceBe treated with respect, kindness, and dignityBe supported by the facility in exercising his/her rights Review of the clinical record revealed that Resident R20 was admitted to the facility on [DATE]. Review of Resident R20's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/9/26, indicated diagnoses of high blood pressure, hyperlipidemia (high fat in the blood), and anxiety. During an observation on 6/7/26, at 10:58 a.m. two signs were observed above Resident R20's bed that read: Please see nurse prior to giving water cup and needs hearing aids put on charger every night, use dry erase board. Review of Resident R20's clinical record failed to include any documentation that the above residents or their representatives approved the posting of private health information. During an interview completed on 6/8/26, at 10:42 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed the two signs were posted above Residet R20's bed and that the facility failed to maintain residents' confidential personal medical record for one of two residents (Resident R20). 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of three residents (Resident R8, and R58). Findings include: Review of the facility policy Cleaning and Disinfection of Resident Care Items and Equipment last reviewed 4/30/26, indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and the OSHA Bloodborne Pathogen Standard. Review of the facility policy Infection Control last reviewed 4/30/26, indicated the facility adopted infection prevention and control policies to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/8/26, indicated diagnoses of Parkinsons disease (progressive brain disease that affects movement and causes tremors, stiffness and slowness), dementia (decline of brain function) and insomnia (sleep disorder that makes it hard to fall asleep and stay asleep). Review of Resident R8's physician order dated 4/21/26, indicated Enteral Feed (delivers liquid nutrition directly into digestive system using a flexible tube that bypasses normal swallowing) every shift Osmolite 1.5 (formula type) to run 24 hours continuous at 60 milliliter (ml) per hour. Free water flushes with 50 ml every hour. During an observation completed on 6/7/26, at 10:40 a.m. the enteral feeding pole was found soiled with what appeared to be spilled or leaked enteral formula which was dried covering the bottom surface of the pole. During an interview completed on 6/7/26, at 11:22 a.m. Registered Nurse (RN) Employee E1 confirmed dried enteral formula was covering the bottom surface of the pole and that the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of three residents (Resident R8). Review of facility policy Enteral Tube Feeding via Syringe (Bolus) dated 4/30/26, indicated to check the order to verify the type, amount, method and rate of administration. Verify placement of tube. Attach a 60-milliliter syringe to the tube and elevate syringe approximately eighteen inches above the resident's head. Fill the syringe with the prescribed amount of enteral feeding to be given. Unclamp the tube and allow feeding to flow by gravity. Review of the admission record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's MDS dated [DATE], indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R58's physician order dated 5/23/26, indicated enteral feed order three times a day for nutrition - Osmolite 1.5 bolus one can (eight fluid ounces). Observation on 6/7/26, at 12:05 p.m. of Licensed Practical Nurse (LPN) Employee E4 administering Resident R58's bolus feeding, the following was observed:-LPN drew the feeding solution into the syringe and connected the syringe to the feeding tube.-Opened the clamp and pushed plunger of syringe to administer the feeding. Interview on 6/7/26, at 12:06 p.m. LPN Employee E4 indicated the feeding tube flows without problems when asked if the feeding tube clogged easily. During an interview on 6/7/26, at 2:00 p.m. the Director of Nursing confirmed that the bolus feeding procedure should be done by gravity and not forced by a syringe plunger. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R11).Findings include: Review of facility policy Trauma Informed Care last reviewed 4/30/26, indicated to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Triggers are highly individualized. Develop individualized care plans that address past trauma in collaboration with the resident and family. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's MDS (minimum data set - a periodic assessment of care needs), dated 3/18/26, indicated diagnosis of anxiety, depression, and bi-polar disorder (mental health condition that causes extreme mood swings). Review of Resident R11's current care plan revealed survivor of trauma related to experiencing abuse either physical, sexual, verbal or mental abuse but failed to identify triggers to prevent re-traumatization. During an interview on 6/9/26, at 11:50 a.m. Social Worker Employee E17 confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two (Resident R11). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for one of three observed days (6/7/26).Findings include: Observation conducted on 6/7/26, at 9:00 a.m., indicated that nurse staffing information was posted on the wall of the nurses' station nearest to the dining room. At that time, the nurse staffing information had the date of (6/4/26), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. Interview with Registered Nurse (RN) Employee E1 5/26/26, at 9:00 a.m., confirmed the facility failed to post the required current facility information for staffing hours and the facility census. 201.18(b)(3) Management.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of two medication storage rooms (Front Hall Medication Room) and two of three medication carts (Zone 2 Medication Cart and Zone 3 Medication Cart). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed 4/30/26, indicated medications are stored in an orderly manner in cabinets, rooms, refrigerators and carts. Medications requiring refrigeration are stored in a refrigerator located in the medication room. Medications are stored separately from food and are labeled accordingly. Medications for external use are stored separately from other medications. Medications and biologicals are stored in the packaging in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation completed on 6/7/26, at 11:23 a.m. the Front Hall Med Room Contained the following: A pair of black athletic shoes stored under the sink. A box of medication cart dividers stored under the sink. A black travel coffee cup on the counter near the sink. A Reacher for picking up items on the counter near the sink. The medication room refrigerator contained the following: 2 bottles of Lansoprazole oral liquid open and not labeled with a date as required. 4 Tylenol Suppositories lying on the bottom shelf not stored in packaging as required. The medication room refrigerator freezer section contained: 2 ice packs During an interview completed on 6/7/26, at 11:31 a.m. Registered Nurse (RN) Employee E1 confirmed the above observations and that the facility failed to properly store medications in the Front Hall Medication Room. During a Medication Cart observation completed on 6/7/26, at 11:39 a.m. the Zone 3 Medication Cart contained the following: A Sodium Chloride inhaler opened and not labeled with a date as required. 2 boxes of Albuterol nebulizer solution opened and not labeled with a date as required. A Fluticasone Propionate nasal spray opened and not labeled with a date as required. A box of Bisacodyl Suppositories stored with oral medications. During an interview completed on 6/7/26, at 11:46 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the above observations and confirmed that the facility failed to properly store medications in the Zone 3 Medication Cart. During an observation completed on 6/8/26, at 9:05 a.m. The Zone 2 Medication Cart contained the following: 6 boxes of Ipratropium Bromide opened and not labeled with a date as required 1 package of Budesonide opened and not labeled with a date as required. During an interview completed on 6/8/26, at 9:05 a.m. LPN Employee E2 confirmed the above observations and that the facility failed to properly store medications in the Zone 2 Medication Cart. 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals (lunch meal 6/7/26) and failed to have the registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served (lunch meal 6/7/26). Findings include: Review of the facility policy Dietician last reviewed 4/30/26, a qualified, competent, and skilled dietician will help oversee the food and nutrition services in the facility. The dietician is responsible for, but not limited to: . Assessing the nutritional needs of residents. . Developing and evaluating regular and therapeutic diets. Review of the facility policy Menus last reviewed 4/30/26, indicated menus are developed and prepared to meet resident choices while following established national guidelines for nutritional adequacy. The dietician reviews and approves all menus. The posted 4-week menu cycle for 6/7/26, was observed and indicated the following: fried chicken, gravy, mashed potatoes, Brussel sprouts, chocolate chip cookie, coffee or tea, milk. Lunch observations indicated that the lunch meal served on 6/7/26, did not match the resident posted menu. During observations on 6/7/26, at 12:09 p.m. main dining room was observed with lunch service being provided for 22 residents. During observations on 6/7/26, at 12:23 p.m. Resident R6 meal was observed and his lunch tray included turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, and a juice in cup. During an observation completed on 6/7/26, at 12:38 p.m. Resident R33's lunch tray included turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, chocolate chip cookie and beverage in cup. During an observation completed on 6/7/26, at 12:40 p.m. Resident R13's lunch tray consisted of turkey, mixed vegetables (corn, green beans, carrots), cheese potatoes, and beverage in cup. During an interview completed on 6/7/26, at 12:30 p.m. upon asking Dietary Manager Employee E12 concerning the lunch meal changes stated, it was changed due to an issue with the cooler. Upon asking Dietary Manager Employee E12 if the dietician had approved the menu changes replied, I think I e-mailed it to her. Upon looking for the e-mail Dietary Employee E12 could not find any correspondence to the dietician and confirmed that the dietician did not sign off on the menu changes as required and confirmed facility failed to follow the displayed menu for one of three observed meals (lunch meal 6/7/26) and failed to have the registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served (lunch meal 6/7/26). Pa Code: 201.18(b)(1) Management.

Based on observation and staff interview, it was determined that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building.Findings include: Review of the facility policy Food-Related Garbage and Refuse Disposal last reviewed 4/30/26, indicated garbage and refuse containing food waste will be stored in a manner that is inaccessible to pest. Outside dumpsters will be kept closed and free of surrounding litter. During an observation completed on 6/7/26, at 9:22 a.m. the outside dumpster lid was open with debris scattered on the ground. During an interview completed on 6/7/26, at 9:22 a.m. Dietary [NAME] Employee E13 confirmed the dumpster lid was open and there was debris scattered on the ground and stated, I haven't gotten to it yet, we usually clean it up in the morning and confirmed that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for one of three residents (Resident R58) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026).Findings include: Review of the facility policy Enhanced Barrier Precautions dated 4/30/26, indicated enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP employ targeted gown and glove us in addition to standard precautions during high-contact resident care activity. An example of high-contact resident care activity includes device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator etc.). Review of facility policy Infection Prevention and Control Plan dated 4/30/26, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Review of the admission record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R58's physician order dated 5/23/26, indicated enteral feed order three times a day for nutrition - Osmolite 1.5 bolus one can (eight fluid ounces). Review of Resident R58's physician order dated 5/25/26, indicated EBP: G-tube/surgical incision right groin. Requires utilization of gowns and gloves during high contact resident care activities. Observation on 6/7/26, at 12:05 p.m. of Licensed Practical Nurse (LPN) Employee E4 administered Resident R58's bolus feeding through the G tube. LPN Employee E4 did not put on a gown as required with EBP. Review of the facility's monthly tracking of surveillance on 6/9/26, for the period of June 2025, through May 2026, failed to include surveillance tracking to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026). Interview on 6/9/26, at 12:15 p.m. Infection Preventionist Employee E18 confirmed that a gown is to be worn during administration of a tube feeding and that the facility failed to include surveillance tracking to identify possible communicable diseases or infections for two of 12 months (July 2025, and April 2026). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessment for one of four sampled residents (Resident R1).Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated [DATE], indicated the significant change status assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The assessment reference date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). The facility Certifying accuracy of the resident assessment policy last reviewed on 4/30/26, indicated that the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment dated [DATE], indicated he had the following diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), acute kidney failure, hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination). Review of Resident R1's care plans dated 4/29/26, indicated that he was admitted to hospice. Comfort measures only CMO with the potential for weight loss. Review of Resident R1's social services note dated 4/28/26, indicated that the social worker spoke to Resident R1 about the topic of Hospice. He stated that he is Alert and Oriented and that he knows his rights and that he wants to drink thin liquids and eat what he wants. He stated he wanted to begin Hospice care. Social services provided Resident R1 with a list of Hospice Agencies, and he chose a provider. Review of Resident R1's physician orders dated 5/13/26, indicated that he was ordered hospice care services. Review of Resident R1's MDS assessments did not include a significant change MDS assessment that included hospice services for Resident R1. During an interview on 6/8/26, at 10:27 a.m. the Regional clinical director Employee E15 and the Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E16 confirmed that the facility failed to conduct a Significant Change Minimum Data Set assessment for Resident R1 as required. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (July 2025, and April 2026) and failed to provide a complete antibiotic order for one of four residents (Resident R33). Findings include: Review of facility policy Antibiotic Stewardship dated 4/30/26, indicated as part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist or designee. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following: drug name, dose, frequency of administration, duration of treatment, route of administration, and indications for use. Review of the facility's Infection Control surveillance for June 2025, through May 2026, failed to include documentation to indicate that antibiotic monitoring was completed for July 2025, and April 2026. Interview on 6/9/26, at 12:15 p.m. Infection Preventionist Employee E18 confirmed the facility could not produce documentation to indicate that antibiotic monitoring was completed for July 2025, and April 2026. Review of the clinical record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's MDS (minimum data set - a periodic assessment of care needs), dated 3/18/26, indicated diagnoses of hypertension (high blood pressure), hyperlipidemia (high fat in the blood) and anxiety. Review of Resident R33's physician orders dated 6/3/26, indicated Cephalexin Capsule 500 milligram give one capsule by mouth every eight hours for infection. The order failed to include the type or site of infection. During an interview completed on 6/8/26, at 2:09 p.m. Infection Preventionist Employee E18 confirmed Resident R33's physician order for antibiotic treatment did not contain the type of infection or the site of the infection and that the facility failed to provide a complete antibiotic order for one of four residents (Resident R33). 28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for two periods during the time frame from June 2025, through May 2026 (11/12/25 - 11/24/25, and 4/26/26 - 5/20/26).Findings include: Review of the facility policy Infection Preventionist dated 4/30/26, indicated the infection preventionist (IP) coordinates the development and monitoring of the infection prevention and control program. The IP is employed on site and at least part time. Review of the facility provided document IP Timeline on 6/8/26, indicated the following IPs were responsible during the following time frames for the period of June 2025 - May 2026:-RN Employee E5 was responsible 5/1/24 - 11/12/25.-IP Employee E19 was responsible 11/13/25 - 3/5/26. -IP Employee E18 was responsible 3/5/26 - present. Review of IP Employee E19's certificate for qualifying education required was dated 11/24/25; therefore, there was not a qualified IP designated from 11/12/25, through 11/24/25. Review of facility provided documentation indicated IP Employee E19 became the Director of Nursing on 4/26/26. Review of IP Employee E18's certificate for qualifying education required was dated 5/20/26; therefore, there was not a qualified IP designated from 4/26/26, through 5/20/26. Interview on 6/8/26, at 2:00 p.m. the Director of Nursing confirmed there were two periods of IP designation gaps between 11/12/25 - 11/24/25, and 4/26/26 - 5/20/26. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, observations, resident and staff interviews, it was determined that the facility failed to make certain resident funds were accessible on holidays and weekends for two of four residents reviewed (Residents R1 and R2).Findings include: Review of the facility Resident Trust Account Withdrawals when the Business Office is Closed indicated residents must be able to access their funds, even when the business office is closed. If a resident needs to withdraw money from their trust account outside of regular business hours, the following procedures must be followed that include but not inclusive to: A bank bag containing cash is kept locked in the Registered Nurse (RN) office. RNs may only issue the amount of cash available in the bag. If additional funds are requested, contact the Administrator immediately During an interview completed on 9/29/25, at 10:04 a.m. upon asking Resident R1 concerning access to her funds stated I asked one time during the weekend, and I could not get any it was on a Saturday a few weeks ago, they were going to set something up moving forward for availability on the weekends. I have not asked again on the weekend, I just ask during the week. During an interview completed on 9/25/25, at 12:00 p.m. upon asking Resident R2 concerning access to her funds stated, I have asked the other day for two twenty-dollar bills and one ten-dollar bill, I still have not gotten it. During an interview completed on 9/25/25, at 10:25 a.m. upon asking RN Employee E3 concerning resident request for funds on the weekends replied, I would tell them they would have to wait until Monday, I don't believe they have any money on the cart. During an interview completed on 9/25/25, at 10:28 a.m. upon asking Nurse Aid (NA) Employee E4 concerning resident request for funds replied I tell them they have to go to the business office or have the business office come see them. If it was on the weekend would let them know no one was in the office. I don't think anyone has access to the funds on the weekends as far as I know. During an interview completed on 9/29/25, at 10:50 a.m. upon asking RN Employee E6 concerning resident request for funds replied, Usually they go to the business office, I know they have been talking about having petty cash available, nothing has been put into place yet. During an interview completed on 9/29/25, at 11:04 a.m. upon asking Licensed Practical Nurse (LPN) Employee E5 concerning resident request for funds replied The process is the business office, the nurses do not have any way to get money. I don't know what would happen on a weekend, there is nothing kept in the cart for the residents. During an interview completed on 9/29/25, at 11:20 a.m. the Maintenance Director Employee E2 stated I am temporarily taking care of the business office. We have a new business office manager starting soon and a regional office person is also helping. Upon asking Employee E6 concerning the process if the business office is not available replied On the weekends we have a withdraw book where the RN supervisor would have access to it. The process is the same, there is a log with carbon copies. This has recently been put into place around early spring. Because someone wanted funds on the weekend. The supervisors will get it. The Business office keeps $500.00 on hand. During an interview and observation completed on 9/29/25, at 1:05 p.m. upon asking RN Employee E1 concerning residents request for funds when the business office is not available replied it's supposed to be in the cart, I think. RN Employee E1 went to obtain the nurse who was responsible for the cart. Upon RN Employee E1 returning to the back hall nursing station it was revealed that cash is not kept in the cart, it is in a locked box outside of restroom area at back hall nursing station. During an interview on 9/29/25, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide residents with access to their funds on weekends and holidays as required. 28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a) Resident rights.

Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal). Findings include: The facility policy Menus reviewed 3/10/25, indicated menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. The dietician reviews and approves all menus. During a dining observation on 5/27/25, at 5:07 p.m. the resident's dinner meals failed to match the approved facility menu for dinner on this date. On 5/27/25, the facility menu was approved by the Registered Dietician (RD) as follow: - Minestrone Soup - Whole wheat crackers - Tuna salad plate - Carrot raisin salad - Mandarin oranges - Coffee, tea, milk On 5/27/25, the facility served residents the following: - Beef vegetable or chicken noodle soup - Whole wheat crackers - Tuna salad plate - 3 bean salad - Mandarin oranges - Coffee, tea, milk During an interview on 5/27/25, at 5:47 p.m. [NAME] Employee E14 stated, We didn't have any Minestrone soup, so I made beef vegetable and chicken noodle soup, and We didn't have any carrot raisin salad, so I served 3 bean salad instead. [NAME] Employee E14 stated, We don't have a lot of stuff on the menu. During an interview on 5/27/25, at 6:01 p.m. Dietary Manager Employee E1 stated, The company makes the menus, the RD approves the menus and then we change it around sometimes. I don't get the RD to review the changes and sign off on it. During an interview on 5/27/25, at 6:05 p.m. Dietary Manager Employee E1 confirmed that the facility failed to follow the displayed menu for one of three observed meals on 5/27/25, (Dinner Meal). Pa Code: 211.6(a) Dietary services.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings include: Review of facility policy Date Marking for Food Safety, dated [DATE], indicated the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food the time the food is opened or prepared. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Review of facility policy Food Preparation and Service, dated [DATE], indicated food and nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illnesses. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food and nutrition services staff wear hair restraints (hair net, beard net) so that hair does not contact food. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. Review of facility policy Dishwasher Temperature, dated [DATE], indicated the facility will ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. During an observation on [DATE], at 1:15 p.m. in the freezer storage area of the Main Kitchen, the following were observed to be opened and without a date: - Half a bag of bacon pieces, no dates noted During an observation on [DATE], at 1:20 p.m. in the walk in cooler area and refrigerator of the Main Kitchen, the following were observed to be opened and without a date or expired: - Ham slices, open date [DATE] and expiration date of [DATE]. - Container of sour cream, opened with no expiration date. - Pineapple salad made [DATE] and expiration date of [DATE]. - Mayonnaise dated [DATE] and expiration date of [DATE]. - Mixed fruit, expiration date of [DATE]. During an interview on [DATE], at 1:25 p.m. Dietary Manager Employee E1 confirmed the above findings, and confirmed that the facility failed to monitor food expiration dates. During an observation on [DATE], at 1:27 p.m. the walk-in cooler fans, ceiling and walls had grim built up on them and the five vents on the ceiling in the main kitchen area had grim built up around them. During an interview on [DATE], at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observations and stated, I will get them cleaned right away. During tray line observation on [DATE], at 11:45 a.m., [NAME] Employee E3 and [NAME] Employee E4 was noted to have a beard and did not have on a beard net. During an interview on [DATE], at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observations and stated, I will get some ordered, we don ' t have any. During tray line observation on [DATE], at 11:48 a.m. seven lids that cover resident plates fell off a cart onto the floor. [NAME] Employee E3 picked up the lid covers and proceeded to use them. State Agency surveyor intervened and stopped the staff member from using on resident meals. During an interview on [DATE], at 1:45 p.m. Dietary Manager Employee E1 confirmed the above observation. During an observation in the Main Kitchen dish room, on [DATE], at 9:30 a.m. it was revealed that the facility does not verify the final rinse temperature of the dish machine by running a temperature test strip through the dish machine to verify the operating condition of the dish machine. During an interview on [DATE], at 9:40 a.m. Dietary Manager Employee E1 stated, We don't check the temperature with temperature test strips. I will get a log together and order new strips because I don ' t know how old the current ones are. During an interview on [DATE], at 12:02 p.m., Nursing Home Administrator confirmed that the facility failed to properly monitor food expiration dates in the Main Kitchen, failed to maintain food equipment in a clean, sanitary condition, failed to properly restrain beards, failed to maintain sanitary conditions during tray line which created the potential for cross contamination, and failed to verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management.

Based on facility policy, pest control log, observations, and staff interviews it was determined the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen). Findings include: Review of the facility Pest Control policy dated 3/10/25, indicated that the facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a kitchen tour on 5/27/25, at 1:00 p.m. an observation of the storage room where dry foods are stored had an abundance number of gnats on the boxes/cans of goods or were flying around in the area. During an observation on 5/27/25, at 1:10 p.m. gnats were observed flying around the main kitchen area above the prep table and around the dish machine. During an observation on 5/27/25, at 1:30 p.m. mounted bug lights were observed hanging on the wall by the door and in the back storage area where the ice machine is kept. During an interview on 5/27/25, at 1:33 p.m. Dietary Manager Employee E1 stated, I've been here for three months and have been trying to fix the gnat problem, and confirmed the above observations. During an observation on 5/28/25, at 11:30 a.m. gnats were flying throughout the kitchen while staff were working. An observation of approximately 40 gnats on the wall beside the microwave were observed. During an interview on 5/28/25, at 11:45 a.m. [NAME] Employee E3 stated, These gnats are terrible. They are everywhere. During an interview on 5/28/25, at 11:50 a.m. [NAME] Employee E4 stated We had a problem with water damage and parts of the ceiling came down last year. I don't think it is fixed properly. The gnats are coming from the moisture, and they have been here for a while. Review of facility provided documentation included pest-control log dated 5/6/25. Inspection report indicated: - Fungus gnats observed in dry food storage (live) - Fungus gnats observed in kitchen (live) - Certain service areas not available for inspection/treatment: Please arrange to have the identified are accessible for inspection or treatment on the next service visit. - Actions Taken: Fungus gnats. Inspected and previous conditions still exist. - Findings: Repair or dry out walls or wood that has been damaged by water During an interview on 5/28/25, at 1:45 p.m. Dietary Manager confirmed that the facility failed to maintain an effective pest control program related to gnats in the kitchen (Main Kitchen). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for 12 of 12 months (April 2024, - April 2025). Findings include: Review of facility policy Infection Prevention and Control Plan dated 3/10/25, indicated an infection prevention and control program is established to maintain and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveillance tools are used for identifying the occurrence of infections, recording their numbers and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. Review of the facility's monthly tracking of surveillance on 5/28/25, failed to include floor mapping for twelve of twelve months April 2024, - April 2025. Interview on 5/28/25, at 12:09 p.m. Infection Preventionist Employee E13 confirmed the facility failed to implement an effective infection control plan as required for the months of April 2024, - April 2025 and was unable to produce the documents with surveillance including floor mapping. 28 Pa. code: 201.14 Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10(a)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56). Findings include: Review of the facility policy Admission Agreement dated 3/10/25, indicated all residents have a signed and dated admission agreement on file. At the time of admission, the resident (or their representative) must sign an admission agreement (contract). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R2's admission record indicated and admitted [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/16/25, indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), multiple sclerosis (immune system eats away at protective covering of nerve cells), and hypertension (the force of the blood against the artery walls is too high). Section C0500 BIMS score of 15. Review of Resident R2's admission agreement indicated a completion date of 5/29/25. Interview with the Nursing Home Administrator on 5/29/25, at 12:29 p.m. indicated Resident R2 did not have an admission agreement completed on admission, so the facility had it completed with Resident R2 today (5/29/25). Review of Resident R12's admission record indicated and admitted [DATE]. Review of Resident R12's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), hypertension, and depression. Section C0500 BIMS score of five - severe impairment. Review of the admission agreement indicated a completion date of 1/28/25, signed by Resident R12. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R12 did not have an admission agreement completed on admitted [DATE], and that Resident R12 did not have the capacity to understand the terms of the admission agreement. Review of Resident R33's admission record indicated and admitted [DATE]. Review of Resident R33's MDS dated [DATE], indicated the diagnoses of dementia, hypertension, and depression. Section C0500 BIMS score of five - severe impairment. Review of the admission agreement indicated a completion date of 3/31/23, signed by Resident R33. Review of Resident R33's census report indicated the following admission and discharge date s: Admit 3/31/23, with discharge 4/8/23. Admit 10/19/23, with discharge 10/23/23. Admit 3/22/24, with discharge 3/31/24. Admit 7/19/24, with discharge 7/30/24. Admit 11/16/24, with discharge 11/22/24. Admit 3/21/25, with discharge 3/26/25. Admit 4/9/25, with discharge 4/20/25. Admit 5/1/25, with discharge 5/5/25. Admit 5/16/25. Interview with the Nursing Home Administrator on 5/29/25, at 1:34 p.m. indicated the facility failed to complete an admission agreement with each admission to the facility and that Resident R33 did not have the capacity to understand the terms of the admission agreement. Review of Resident R56's admission record indicated and admitted [DATE]. Review of Resident R56's MDS dated [DATE], indicated the diagnoses of anemia, hypertension, and stroke (damage to the brain from an interruption of blood supply). Section C0500 BIMS score of eleven - moderately impaired. Review of the admission agreement indicated a completion date of 5/21/25, signed by Resident R56. Interview with the Nursing Home Administrator on 5/29/25, at 1:32 p.m. indicated Resident R12 did not have an admission agreement completed on admitted [DATE], and that Resident R56 did not have the capacity to understand the terms of the admission agreement. Interview on 5/29/25, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to maintain timely documentation of the admission agreement for four of four residents (Resident R2, Resident R12, R33, and R56) and failed to ensure residents had the capacity to understand the terms of the admission agreement for three of four residents (Residents R12, R33, and R56). 28 Pa Code: 201.18(b)(1)(3)Management. 28 Pa Code: 201.24(a) Admission policy. 28 Pa Code: 201.29(a)(b) Resident Rights

Based on review of facility documents, interviews with residents, and staff, it was determined that the facility failed to pay staff in a timely manner as scheduled. This resulted in kitchen staff and multiple nurse aides not reporting to work, which created a situation that placed 50 out of 50 residents in immediate jeopardy in which health and safety were impacted due to a potential interruption of proper food, supplies and services. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of facility staffing schedules revealed the following: Friday 2/23/24, two out of five Nurse Aides (NA) called off on daylight shift, and three out of five NA called off on evening shift. Saturday 2/24/24, one out of four NA called off on daylight shift, and two out of three NA called off on evening shift. Six out of six dietary employees called off. Sunday 2/25/24, one out of three NA employees called off on evening shift, and one out of four NA called off on night shift. Five out of five dietary employees called off. Monday 2/26/24, four out of five NA called off on daylight shift, three out of four NA called off on evening shift, and one out of three NA called off on night shift. During an interview on 2/28/24, at 9:23 a.m. NA Employee E22 stated that staff did not get paid as scheduled on Friday, (2/24/24), but did get paid on Monday (2/26/24). NA Employee E22 stated that she was scheduled off that weekend but was aware that many employees called off that weekend due to not receiving their paychecks on Friday. We never had an issue with paychecks with the previous owners. During an interview on 2/28/24. at 9:25 a.m. NA Employee E15 confirmed that staff did not receive their paychecks as scheduled and Never, ever had these problems before. During an interview on 2/28/24, at 9:53 a.m. Assistant Nursing Home Administrator (ANHA) confirmed that the staff did not receive their scheduled paychecks on 2/23/24, and that they had a lot of call offs that weekend. During an interview on 2/28/24, at 12:01 p.m. MDS (minimum data set- periodic assessment of resident care needs) Coordinator Employee E13 stated Lately we've had no agency (nursing staff). I think it's because they weren't being paid. We were pretty good there for a while until we didn't get paid the second time. During a group interview on 2/28/24 at 1:31 p.m. the following was stated: One out of 11 residents stated On Friday, Saturday, Sunday, and Monday ( 2/23/24, 2/24/24, 2/25/24, and 2/26/24), staff did not get paid and did not show up. One out of 11 residents stated They asked us to stay in bed the day that they did not get paid. One out of 11 residents stated There was no kitchen staff. We had two donuts from Dunkin' Donuts and lunch was pizza, That was on Saturday (2/24/24). 11 out of 11 residents stated that there were no nurse aides on Saturday (2/24/24). One out of 11 residents stated We did not see any management at the home (on Saturday 2/24/24). During an interview on 2/28/24, at 2:01 p.m. Nurse Aide (NA) Employee E4 stated that she called off on Saturday 2/24/24 Because I was mad. They didn't pay us on Friday. They have had issues with not paying us in the past and we are sick of it. During an interview on 2/28/24 at 2:30 p.m. the Dietary Director Employee E5 confirmed that dietary staff failed to show up for work on 2/24/24, and 2/25/24, due to not receiving their paychecks on 2/23/24 as scheduled. During an interview on 2/29/24, at 10:05 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that she also did not get paid on 2/23/24, as scheduled but did show up to work on 2/24/24. LPN Employee E6 stated that no one showed up to work in the kitchen on 2/24/24, so the Director of Nursing (DON) had to work in the kitchen and ordered donuts for the residents for breakfast, and that the ANHA called in from home and had pizza delivered to the residents for lunch. LPN Employee E6 also stated that no other management or administrator was in facility on 2/24/24, during the time she worked which was from 7:00 a.m. to 4:30 p.m. During an interview on 2/29/24, at 12:31 p.m. DON stated that beautician quit in October because she was not getting paid and have not had anyone in this role since then. DON also confirmed that staff had called off on Saturday (2/24/24), when they had not yet received their scheduled paychecks on 2/23/24. DON further explained that she had been woken up at 4:30 a.m. on 2/24/24 via multiple text messages and phone calls about staff calling off. DON stated that she came into the facility on [DATE], and ordered donuts for the residents for breakfast, and that pizza was ordered for lunch. DON stated that for dinner on 2/24/24, they had kitchen staff from a sister facility come in to prepare food, as well as for all meals on Sunday, 2/25/24. On 2/29/24, at 1:30 p.m., the ANHA was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for 50 out of 50 residents in which health and safety were impacted due to a potential interruption of proper food, supplies and services., and a corrective action plan was requested. On 2/29/24, at 5:14 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Facility staff were paid on 2/26/24. Facility instituted an employee fund for any monetary needs until payroll processed. Funds were made available via Cash App, [NAME], and Quick Pay. Facility implemented bonus program for shift pick up and sign-on bonuses for new hires. Residents: Secured contract with Ready Shift Staffing to provide staff for facility if there are any call offs. Management staff will be on-site to assist with patient care needs as suited to qualifications. System Correction: Facility has changed scheduling and payroll companies to consolidate into one and are now splitting facility payrolls to improve cash flow week to week. All facilities will be paid 3/8/24 Payroll will then be split into a new payroll cycle. BHG, [NAME] Hills, Scottdale, and [NAME] with first pay on 3/15/24. Lakeview, Ridgeview, and [NAME] with first pay on 3/22/24. Payroll is submitted the Wednesday of payroll week. Once submitted, email is sent to company controller with amount of funds that will need to be transferred. The company controller will email facility NHA when wire funds have been transmitted. Monitoring: Facility NHA, DON, and Scheduler will review staffing daily for a seven day rolling period to ensure staffing meets PPD and ratios. During an interview on 3/2/24, at 1:40 p.m. NA Employee E23 confirmed that she did not get paid on 2/23/24, as scheduled but got paid on 2/26/24. NA Employee E23 stated that the previous payday on 2/9/24, they received their paychecks late. We are supposed to get them at midnight as soon as it becomes Friday, but they didn't give them to us until 5:00 p.m. They also paid us one time in October, and then took the money out of our accounts a few days later. We are scared for next payday. During an interview on 3/3/24, at 11:35 a.m. Housekeeper Employee E24 stated We work hard and we expect to be paid. Without workers what would you have?. During an interview on 3/3/24, at 11:40 a.m. NA Employee E15 stated I don't think we are going to get paid (regarding the upcoming payday on 3/8/24). It's scary. If they would just be honest with us. If I'm not paid I would probably not come in on Monday and I've never called off. During an interview on 3/3/24, at 11:50 a.m. an anonymous employee confirmed that she also did not receive a paycheck as scheduled on 2/23/24, and added First time ever my car payment was late. When anonymous employee was asked if she would come into work if this happens on the next scheduled payday (3/8/24), she replied, I won't come to work. The writing is on the wall. If I don't get paid on Friday I'm not coming back. I think they did this on purpose- squeeze out every penny and then bankrupt them . During an interview on 3/3/24, at 11:59 a.m. LPN Employee E25 stated After seeing what happened with [NAME] (facility owned by the same company that closed earlier in the week as employees had not gotten paid and many stopped coming to work), if we are not paid on Friday, I will l probably not be here Monday. It's just a matter of when to jump ship. The owners must not be afraid to lose a part of their souls. During an interview on 3/3/34, at 12:10 p.m. NA Employee E23 stated that she called off on the weekend and on Monday To apply for other jobs, as she had not received her paycheck, and I will not be here if the paychecks are not here. During an interview on 3/3/24, at 12:20 p.m. NA Employee E21 stated that If I don't get paid Friday, I will not be here. I got another job. During an interview on 3/3/24, at 12:21 p.m. NA Employee E22 stated If we don't get paid Friday (3/8/24), I'm not coming to work until we do. During an interview on 3/3/24, at 12:25 p.m. LPN Employee E14 expressed concern regarding not receiving last paycheck on time. When asked if she would come in to work if not paid on payday, she replied, The right thing to do is come. But honestly, I may not come. Pay stability is not there. During an group interview on 3/3/24, at 12:35 p.m. with Dietary Employees the following was stated: Dietary Aide Employee E27 stated I've never been at a place that you don't get paid on payday. I come on time and do the job to the best of my ability and expect a pay. Cook Employee E28 stated that if he does not get paid on Friday (3/8/24), I won't be coming to work on Saturday or Sunday (3/9/24, and 3/10/24). Dietary Aide Employee E29 stated that he works every weekend and called off the weekend of 2/24/24, and 2/25/24 due to not receiving his paycheck, and if he does not receive his paycheck on 3/8/24, he is Not coming Saturday or Sunday (3/9/24, and 3/10/24). Dietary Aide Employee E30 stated If they don't pay again this will be the fifth time we haven't gotten paid or pay was messed up. Dietary Aide Employee E30 indicated that he works every weekend and will not report to work again if he does not receive his paycheck, and added that the company is Not trustworthy to even get paid. Cook Employee E31 stated she will not be coming to work if they do not get paid. During an interview on 3/3/24, at 2:00 p.m. Resident R25 stated that kitchen staff had not come in the previous weekend due to not getting paid. It was pretty bad. I'm diabetic and I got donuts for breakfast and I don't like pizza. I've heard the employees are getting out of here. It's sad. I love these people and I feel bad for them if they don't have money. I don't have anywhere else to go. The Immediate Jeopardy was lifted on 3/4/24, at 4:24 p.m. when the action plan was verified. During an interview on 3/5/24, at 4:15 p.m. the ANHA confirmed that the facility failed to pay staff in a timely manner as scheduled, which resulted in kitchen staff and multiple nurse aides not reporting to work, which created a situation that placed 50 out of 50 residents in immediate jeopardy in which health and safety were impacted due to a potential interruption of proper food, supplies and services. 28 Pa. Code 201.14(g) Responsibility of licensee. 28 Pa. Code 201.18(e)(1)(2) Management.

Based on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 50 residents (Resident R48). Findings include: The facility Wandering and elopements policy last reviewed 9/28/23, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. If an employee observes a resident leaving the premises, staff should attempt to prevent the resident from leaving, get help from other staff, and instruct another staff to inform the charge nurse. When the resident returns to the facility, the charge nurse shall examine the resident for injuries, contact the physician and report findings, notify the resident's legal representative, and complete and file an incident report. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R48's admission record indicated she was admitted on [DATE], with diagnoses that included 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), Post-concussion syndrome (lingering symptoms such as headache or confusion after a concussion), depression, hypertension (a condition impacting blood circulation through the heart related to poor pressure), altered mental status (symptoms indicative of brain malfunction with symptoms such as forgetfulness, confusion and behavioral changes), and a history of falling. Review of Resident R48's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/18/24, indicated that the diagnoses were the most recent upon review. Review of Resident R48's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 5 revealing that Resident 48 was not alert and oriented, and had a severe cognitive impairment. Review of Resident R48's care plan dated 1/12/24, indicated resident was an elopement risk related to concussion symptoms and wandering behaviors, alarming bracelet in place, and nursing staff provide supervision. Review of Resident R48's elopement risk assessment dated [DATE], indicated that resident was cognitively impaired with poor decision making skills, was at risk for elopement, and exhibited wandering behaviors. Review of Resident R48's physician orders dated 1/16/24, indicated to provide alarming security bracelet. Review of facility submitted documentation dated 2/29/24, indicated on Tuesday, 2/27/24, at approximately 3:15 p.m. Resident R48 was observed by staff outside of the building walking in the parking lot of the facility. Staff members immediately went outside and walked her back into the building. There were no injuries and when asked Resident R48 stated, I'm just walking the dogs. It's such a beautiful day. Resident was last seen walking in hallway approximately 15-minutes prior to being seen in the parking lot. Resident R48 was unable to tell staff which door Resident R48 exited but it was assumed to be the main entrance as multiple staff were present at the back entrance and claim they would have seen her if she exited that door. Resident R48 had a wanderguard security device placed on admission, no alarm sounded when she exited the building, no staff observed her by an exit or actively exiting the building. Maintenance Supervisor Employee E7 was conducting a check of the fire alarm system at that time, which does unlock the doors, but stated the doors were only unlocked for three to five seconds. Review of Activity Aide Employee E10's incident/witness statement dated 2/27/24, indicated that Resident R48 was leaving behind the back nurses station when she witnessed Resident R48 outside. Activity Aide Employee E10 and other staff immediately went outside and redirected Resident R48 back inside. Review of Nurse Aide Employee E8 incident/witness statement dated 2/27/24, indicated that Activity Aide Employee E10 alerted staff that Resident R48 was outside. Staff ran outside and escorted her back into the building. Prior to seeing her, the fire alarm was being tested . Review of Nurse Aide Employee E9's incident/witness statement dated 2/28/24, indicated that she was gathering her things to leave when Activity Aide Employee E10 alerted staff that Resident R48 was outside. Review of Resident R48's clinical record after the elopement on 2/27/24 did not include a complete full body assessment immediately after the incident, an incident report regarding the elopement, or the implementation of 15-minute checks to ensure supervision of Resident R48. Review of Resident R48's clinical record after the elopement on 2/27/24, the Medication Administration Record (MAR) February for 2024 did not include 15-minute checks until 2/29/24. No other documentation of interventions was identified on Resident R48's record. During an interview on 2/29/24, at 10:20 a.m. the Director of Nursing (DON) stated: The wander guard did not go off and we do not know why. No one heard the alarm when she left the building. The wander guard was replaced and worked fine. I don't think an assessment was done immediately after the elopement. Activity Aide Employee E10 went and told Assistant Nursing Home Administrator/Director of Social Services Employee E1. Assistant Nursing Home Administrator/Director of Social Services Employee E1 was not certain Resident R48 was outside. During an interview on 2/29/24, at 12:38 p.m. Speech Therapists Employee E11 stated: I did not see Resident R48 leave the door. I left at 2:53 p.m. on 2/27/24 and I did not see her when I was leaving. During an interview on 2/29/24, at 1:06 p.m. Activity Aide Employee E10 stated the following: I was on break behind the nurse station. I looked up and saw Resident R48 go past the window. We went outside and redirected her back in. It was me, Nurse Aide Employee E8, Nurse Aide Employee E9, and Maintenance Supervisor Employee E7. They were by the back door. It was Tuesday, the weather was not bad. Resident R48 was not hurt/injured. You think the wander guard would of went off. Staff walked her to the front door. Resident R48 was talking normal. I'm not sure which door she exited. Incident occurred around 3:20 p.m. or 3:25 p.m. on 2/27/24. During an interview on 2/29/24, at 1:10 p.m. Nurse Aide Employee E8 stated the following: I was charting at the nurse station. I was about to leave. Activity Aide Employee E10 looked up and said Resident R48 was outside. Resident R48 was outside by herself with a coffee cup in her hand. She said resident was walking her dogs and it was a beautiful day. I walked with her and brought her into the building. It was nice outside. not cold. maybe 60 degrees. The incident occurred around 3:15 p.m. or 3:20 p.m. Nurse Aide Employee E8 was asked how does nursing staff account for residents, and she stated: they have the wander guard on, they cannot get in or out without the wander guard on. we check on the residents per hour. The nurse tells us which residents are wandering residents and residents are accounted for every hour. Maintenance Supervisor Employee E7 tested the fire alarm and from what I understood and the wander guard was not working. Resident R48 was not harmed or injured. There is no wander guard on the back door, only one at the front door. During an interview on 2/29/24, at 1:16 p.m. Nurse Aide Employee E9 stated the following: I came back and sat down at the back hall nurse station. I was close to leaving. Activity Aide Employee E10 stated that Resident R48 was outside. We ran to the backdoor, found Resident R48 in the parking lot and found her safe. Resident R48 kept saying she wanted to go for a walk. She was not harmed or injured. Resident R48 was wearing long sleeves and pants. The time was close to 3:23 p.m. that is when I punch out to leave. Residents are accounted by staff and we do rounds. That is done per shift at the start of the shift. Nurses tell us who are the wandering residents. I did not hear an alarm. There is no alarm at the back door. They changed her bracelet. During an interview on 2/29/24, at 1:22 p.m. Maintenance Supervisor Employee E7 stated the following: I was standing by room [ROOM NUMBER] and heard someone say that Resident R48 was outside. I looked out the window and saw Resident R48 walking in the parking lot. I saw an aide escort her back in. I have no idea how she got out. The back door does not have a wander guard alarm. Someone will come in on Monday to give us a quote for an alarm. During an interview on 2/29/24, at 2:05 p.m. the Director of Nursing (DON), Regional Clinical consultant Employee E12, and Assistant Nursing Home Administrator/Director of Social Services Employee E1 were notified that Immediate Jeopardy (IJ) was called due to the elopement on 2/27/24, and facility staff were provided an Immediate Jeopardy (IJ) template at that time, and a corrective action plan was requested. On 2/29/24, at 5:14 p.m. an immediate action plan was received and accepted which included the following interventions: 1. Elopement reassessment of all residents. 2. Resident R48 placed on q-15 minute checks. 3. Resident R48 care plan updated. 4. Resident R48 wander guard replaced and tested . 5. Resident R48 body assessment to rule out injury. 6. Update to Elopement policy to add q-15 minute checks after an elopement incident. 7. Complete whole house education with all staff on elopement policy/procedure, elopement binder, and appropriate supervision by 12:15 p.m. on 3/1/24. 8. Elopement book will be maintained, updated regularly, and staff educated on location of elopement book. 9. Reassess all current residents with wander guards to ensure function, completed by Maintenance Supervisor Employee E7. On 3/1/24, at 9:12 a.m. all residents assessments for elopement risk were observed and found to be completed. The elopement policy was updated, and documentation verifying all current residents with wander guards function correctly, and careplans were review and updated if needed. During interviews of staff working on 3/1/24, between 12:15 p.m. and 1:40 p.m. staff (22 out of 80 staff persons) confirmed they were trained on the updated elopement policy, what to do during an elopement, the elopement book at the nurse's station and appropriate resident supervision. Verification of the facility's Corrective Action Plan revealed all elements of plan were substantially completed and the Immediate Jeopardy was lifted on at 1:55 p.m. on 3/1/24. During an interview on 3/1/24, at 2:38 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide adequate supervision resulting in Resident R48's elopement. This failure created an immediate jeopardy situation for Resident R48 and potentially put her at risk of harm or injury. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services.

Based on manufacturer's instructions, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed one resident (Resident R37) in immediate jeopardy in which health and safety were impacted. Findings include: Review of the [NAME] Life Vest Patient Manual updated 2023, indicated the following: Wear all day and all night Life Vest slides on and off like a backpack. If the garment fits loosely, call [NAME] (manufacturer). The garment should be snug against the skin. Remove Life Vest to bathe, shower, or change the garment, Turn on Life Vest by inserting the battery. Always have the garment on before inserting the battery. Every 24 hours, change and recharge the batteries. There are two batteries. Always charge one while using the other. Place the charger in a safe place where it can be plugged in. Battery should slide in easily. Do not force the battery into the monitor. Practice changing the battery. Act quickly for siren alerts. Press the response buttons. This alert signals that Life Vest has detected a life threatening rapid heart rhythm. Only the patient should press the response button. If a treatment is received by the Life Vest, leave the Life Vest on and call the doctor. Call [NAME] for a new electrode belt, and check display for any messages and take action. Read the display for [NAME] alerts and follow the instructions on the screen. When connecting and disconnecting the electrode belt be careful not to bend the pins. Remove the battery from the monitor before you remove the garment. Remove the electrode belt from the garment and insert it into a clean garment. Make sure the silver sides of the therapy pads (with the green label) face the mesh of the pocket. Snap the pockets closed. Position and secure the vibration box to the garment. Attach the round electrodes to the garment. Match the colors on the backs of the electrodes to the colors on the garment. Electrodes and therapy pads should press against bare skin. The mesh fabric pockets and silver side of the therapy pads (with green labels) MUST TOUCH BODY for the device to work properly. Do not put the monitor, electrode belt, battery or charger in water; do not get components wet. Call [NAME] immediately if a Call for Service- Message Code 102 appears on the Life Vest screen. A replacement device will be provided within 24 hours from your notification to [NAME]. Wash the garment every 1-2 days. Do not use bleach or fabric softener. If prompted to download data, follow the instructions to do so. Review of the clinical record revealed that Resident R37 was admitted to the facility on [DATE]. Review of Resident 37's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/31/24, indicated diagnoses of dilated cardiomyopathy (a condition in which the heart's main pumping chamber is enlarged. And becomes weaker as it grows larger), Multiple Sclerosis (a disease that affects the central nervous system), and acute respiratory failure (occurs suddenly and interferes with the ability of the lungs to deliver oxygen). Review of Resident R37's Nursing admission evaluation dated 1/24/24, stated Life Vest noted. Review of Resident R37's physician orders revealed an order written on 1/29/24, that indicated, Life Vest. Change and charge battery QD (daily) one time a day related to other cardiomyopathies (heart muscle disease). Review of Resident R37's physician orders revealed an order written on 1/29/24 that indicated Life Vest Check placement, function, skin integrity every shift related to other cardiomyopathies. During an interview on 2/28/24, at 1:45 p.m. MDS Coordinator Employee E13 stated that education was not provided to staff on the care and operation of the Life Vest, but it probably should have. During an interview on 3/1/24, at 9:34 a.m. LPN Employee E6 stated that she had not received any training on the Life Vest for Resident R37. LPN Employee E6 stated that she had a resident in the past that had a Life Vest, and that the facility brought in someone from the manufacturer to educate the staff prior to the resident's arrival, but not for Resident R37. During an interview on 3/1/24, at 10:05 a.m. LPN Employee E14 also verified that she had not received training for Resident R37. During an interview on 3/1/24, at 1:10 p.m. Nurse Aide Employee E15 was asked what she knew about Life Vests and she replied I don't know anything about it or how to operate it. They don't involve the aides. Review of Resident R37's care plan conducted on 3/1/24, revealed no instructions for care and operation of Resident R37's Life Vest. On 3/1/24, at 3:54 p.m., the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, that placed one resident (Resident R37) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. On 3/1/24, at 6:36 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: NHA spoke with [NAME] representative who will be sending educational information overnight to the facility that will pertain all [NAME] Life Vests that may remain in the facility for current and future use. Resident R37's son had package from [NAME] that included instructions, and extra supplies, and was asked to return them to the facility. Residents: Resident R37's physician's orders and care plan were updated System Correction: All present licensed nursing and aide staff will be educated on the [NAME] Life Vest on 3/1/2024 via [NAME] online education by Registered Nurse Supervisor. All licensed nursing and aide staff will be re-educated on the [NAME] Life Vest prior to their shift on their next shift by Director of Nursing/Designee via [NAME] online education. All education will be completed by 3/4/2024. Policy and Procedure for new admissions requiring the use of wearable cardioverter defibrillators now includes in servicing of all licensed nurses and aides upon admission and prior to care. Monitoring: Director of Nursing/Designee will audit all new admissions to ensure current staff has appropriate education for wearable cardioverter defibrillators and/or any other non-standard medical equipment. Tracking and trending will be taken through Quality Assurance Committee for tracking and trending purposes. During an interview on 3/2/24, at 9:35 a.m. Assistant Nursing Home Administrator (ANHA) informed that 11 employees out of 37 had been educated on the Life Vest by watching a video that was on [NAME]'s website and that they were still waiting for the overnight package from [NAME] that would contain education materials. During an interview on 3/3/24, at 11:35 a.m. NHA was asked if the overnight package from [NAME] had arrived, to which she replied No. Overnight does not mean overnight. A link was also requested to the video that staff was watching for education. During an interview on 3/4/24, at 1:30 p.m. ANHA, and NHA informed that 23 out of 37 employees had received Life Vest education via the link on [NAME]'s website. ANHA, and NHA were asked again for a link to this education, to which ANHA replied she cannot figure out how to send the link. State Agency requested a step by step instruction on how to find the particular education that the facility staff was using. State Agency reviewed the educational video on line on 3/4/24, at 1:35 p.m. and found that the education was geared towards 'First Responders, and did not include most of the above education, but provided details on how to use a defibrillator in conjunction with the Life Vest. During an interview on 3/4/24, at 1:45 p.m. NHA was informed that the video that staff was instructed to view as part of Life Vest education did not include appropriate information for daily care. During an interview on 3/4/24, at 1:50 p.m. NHA was asked if the overnight package containing education materials from [NAME] had arrived. NHA then got up and walked down the hall to look and see if it had arrived. During an observation on 3/4/24, at 1:52 p.m. NHA walked into conference room with the package from [NAME] that contained the education materials. Review of these educational materials revealed them to be appropriate. During an interview on 3/5/24, at 12:18 a.m. NA Employee E15 confirmed that she received education on the Life Vest which included information about the different alarms. NA Employee E15 added First of all, I didn't know that it could be washed. I learned a lot. The first education didn't include anything useful for an aide. During an interview on 3/5/24, at 12:40 p.m. NA Employee E26 confirmed that she received education on the Life Vest, and replied This is the first time I ever worked with one. I didn't know anything about them. During an interview on 3/5/24, at 12:55 p.m. NA Employee E32 confirmed that she had received education on the Life Vest and recapped that she learned about the different alarms and that the vest could be removed for showers. NA Employee E32 added At least I know now. During an interview on 35/24, at 1:26 p.m. NA Employee E33 confirmed that she had received education on the Life Vest and stated I was glad I got the education because I have taken care of people before (with a Life Vest) and I never had a good understanding of it. During an interview on 3/5/24, at 2:00 p.m. RN Employee E25 also confirmed that he had received education on the Life Vest, and added he learned new things regarding the risk of shock. The Immediate Jeopardy was lifted on 3/5/24, at 2:43 p.m. when the action plan was verified. During an interview on 3/5/24, at 4:15 p.m. the ANHA confirmed that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Life Vest which created a situation that placed one resident (Resident R37) in immediate jeopardy in which health and safety were impacted. 28 Pa. Code 211.11(d) Resident care plan

Based on review of facility policy, resident clinical record review, staff, and resident interviews, it was determined that the facility failed to follow physician orders which caused a skin graft to be removed which resulted in actual harm, the failure of a skin graft, to one of 24 residents, and to provide treatment and services necessary to promote wound healing (Resident R34). Findings include: Review of the facility Medication and Treatment Orders policy last revised 7/16 indicates orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility Dressings, Dry/Clean policy last revised 9/13, indicated the following: -Verify that there is a physician's order for this procedure -Review the resident's care plan, current orders, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Document wound appearance, including wound bed edges, presence of drainage -Document all assessment data (i.e., wound bed color, size, drainage, etc.) -Document if the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting available alternatives -Document family and physician notification of refusal -Notify the supervisor if the resident refuses the dressing change Review of Resident R34's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R34's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 6/13/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M - Skin Conditions indicated that Resident R34 has surgical wounds. During an interview on 8/2/22, at 1:20 p.m., Resident R34 stated she recently had a left foot skin graft and an agency nurse came into my room for a dressing change and even though I told the nurse the surgeon is the one who does the dressing changes, she proceeded to remove dressing. Instead of the nurse soaking the dressing and slowly taking it off, she ripped the dressing off which resulted in a failed skin graft to her left heel. Review of Resident R34's Foot and Ankle outpatient communication sheet dated 6/20/22 indicated she was scheduled for a bilateral skin substitute graft application on 7/1/22. During an interview on 8/2/22, at 3:32 p.m., the Assistant Director of Nursing (ADON) confirmed she was aware Resident R34's left lower extremity dressing was not to be changed after her surgery on 7/1/22. During an interview on 8/2/22, at 3:34 p.m., the Director of Nursing (DON) confirmed there are multiple wound care orders for the same surgical wound active on Resident R34's clinical record. Review of Resident R34's outpatient surgery discharge instructions dated 7/1/22 at 4:50 p.m., indicated an order to not change dressing. Review of Resident R34's physician's order dated 7/1/22, indicated, Do not change dressing change to left lower extremity with no start date indicated. During an interview on 8/3/22, at 10:49 a.m., the Director of Nursing (DON) confirmed Resident R34 has multiple wound treatment orders for the same surgical wound active, and the Registered Nurse, Employee E4, completed a dressing change on 7/5/22 and 7/6/22 which resulted in a failed skin graft. Review of Resident 34's Treatment Administration Record (TAR) indicated that Registered Nurse Employee E4, documented that the following dressing changes were completed for Resident R34 on 7/5/22 and 7/6/22: -Cleanser BLE wounds with NSS, apply [MEDICATION(S)] to the base of the wounds, cover with 4x4 gauze, webril and Ace Bandage to just below the knee every evening shift. Review of Resident R34's Foot and Ankle Service follow-up report dated 7/14/22, indicated she had an incision and drainage of left heel ulcer with application of skin graft completed on 7/1/22 and the resident stated a nurse changed her dressing and took off the skin graft. The plan indicated it was discussed with the resident that they would like to proceed with a repeat incision and drainage and application of skin substitute graft. Review of Resident R34's operative/procedure note dated 7/29/22, indicated an application of skin substitute graft to left heel measuring 6 x 3.5cm was applied. Review of Resident R34's physician orders are the following: -6/7/22-7/30/22 Cleanser BLE wounds with NSS, apply [MEDICATION(S)] to the base of the wounds, cover with 4x4 gauze, webril and Ace Bandage to just below the knee, every day shift -6/22/22-7/30/22 Cleanse left lower extremity wounds with NSS, cover wounds with 4x4 gauze, apply ABD pad and wrap with Kerlix and ACE wrap, every night shift every Mon, Wed, Fri - 6/22/22-7/30/22 Cleanse right leg wounds with NSS, pat dry, apply 4x4 gauze, kerlix and ACE wrap, every night shift every Mon, Wed, Fri for wounds - Do not change dressing to left le, entered on 7/1/22, with no start date indicated - 7/14/22-7/30/22 Left leg- [MEDICATION(S)] to wound bed with [MEDICATION(S)] soaked 4x4 covered with a dry 4x4, kling wrapping and ace bandage. bandages need to go up to the knee. -7/14/22-7/30/22 Right leg dry 4x4 over hallix eschar, kling wrapping and ace bandage up to knee Review of Resident R34's July Treatment Administration Record (TAR) indicates five of 31 treatments were refused. A review of Resident R34's progress notes failed to reveal that the resident's family, physician, and supervisor were notified of the refusal. Review of Resident R34's Weekly Body Audit for the month of June and July reveals no documentation of site, description, or measurements (including length, width, and depth) of surgical wounds. During an interview on 8/5/22, at 11:19 a.m., the DON and Nursing Home Administrator (NHA) confirmed that the facility failed to provide care and treatment in accordance with physician's orders and professional standards of practice, resulting in actual harm for one of 24 sampled residents (Resident 34). 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5)(e) Nursing services.