Every finding on record at Athens Nursing and Rehabilitation Center

Based on clinical record review, and staff interview, it was determined that the facility failed to provide the highest practical care regarding for physician ordered treatments for three of six residents reviewed (Residents 4, 5, and 6), and physician ordered transfer status for one of one resident reviewed for falls (Resident 2).Findings include: Clinical record review revealed the facility admitted Resident 2 on June 1, 2026. A physician note dated June 2, 2026, at 2:06 PM revealed Resident 2 was admitted to the hospital from [DATE] to 8, 2026 with a femoral neck fracture sustained at another nursing home. Review of Resident 2's care plan-initiated June 1, 2026, revealed Resident 2 has an activity of daily living self-care performance deficit related to his recent hip surgery and noted Resident 2 requires a Hoyer lift transfer with the assistance of two staff members. Review of Resident 2's physician orders revealed a current physician order-initiated June 23, 2026, noting staff are to transfer Resident 2 with a Hoyer lift and assistance of two staff members. Nursing documentation (incident note) dated August 13, 2026, at 8:21 AM revealed registered nurse documentation noting Resident 2 stood up from his recliner chair and fell backwards in between his room and hallway on his back. Documentation revealed the fall was witnessed and Resident 2 did not hit his head. The registered nurse noted Resident 2 was in his chair, and alert but very confused as per his norm. The registered nurse revealed a check of Resident 2's body revealed a blanchable (skin or a red spot that temporarily turns pale or white when you press on it and returns when you let go) area of redness on his back, otherwise his skin is intact, with no apparent injuries observed at this time. Review of facility investigation into Resident 2's fall noted the fall occurred on August 12, 2026, at 2:15 PM. Review of Employee 1's (licensed practical nurse) witness statement confirmed Resident 2 fell on August 12, 2026, at 2:15 PM and the other licensed practical nurse began taking vitals on Resident 2. Employee 1 stated she called the registered nurse supervisor informing her of Resident 2's fall. The witness statement indicated the registered nurse stated, I am on my way back. Before the registered nurse could make it to the unit the nursing home administrator walked over and told staff they needed to get Resident 2 of the floor. Statement revealed nursing staff explained that the registered nurse needed to assess Resident 2 first and that Resident 2 requires a Hoyer lift. Employee 1 statement indicated the nursing home administrator ignored what staff told him and told them to get Resident 2 up anyway. The nursing home administrator then assisted nursing staff with a two-assist transfer from the floor to Resident 2's wheelchair. The registered nurse then arrived on the unit to assess Resident 2. Interview with Employee 1 on August 16, 2026, at 11:41 AM confirmed that Resident 2 was not assessed by the registered nurse prior to moving him, nor was a Hoyer lift utilized to lift Resident 2 off the floor. Further review of the facility investigation revealed Employee 2's statement (licensed practical nurse) noted she witnessed Resident 2 fall out of his chair. She stated she was with Resident 2 waiting for the registered nurse to assess Resident 2 when the Nursing Home Administrator instructed staff to get Resident 2 off the floor. Employee 2 stated she was waiting for the registered nurse assessment, and the Nursing Home Administrator instructed staff to get him up The investigation did not include a statement from the registered nurse. Review of the Nursing Home Administrator's statement revealed he witnessed Resident 2 on the floor, and with the assistance of staff he lifted Resident 2 off the floor and placed him in his wheelchair. Interview with the Nursing Home Administrator on August 16, 2026, at 2:04 PM confirmed that he instructed the staff to assist Resident 2 off the floor prior to the registered nurse assessment, or waiting for the Hoyer lift. The Nursing Home Administrator confirmed that he is not a nurse, but there were no visible injuries. The facility failed to provide Resident 2 with the highest practical care regarding following physician orders and facility practices related to resident falls. A review of current physician orders for Resident 4 revealed an order dated March 3, 2026, for staff to cleanse bilateral buttocks with warm soapy water, pat dry, and apply Calmoseptine ointment (moisture barrier ointment), every day and evening shift for protection/prevention. A review of Resident 4's TAR (treatment administration record, a form utilized to document the administration of resident treatments) dated July 2026 revealed the treatment was not completed per the physician order on July 15, 24, and 28, 2026. A review of Resident 4's TAR dated August 2026, revealed the treatment was not completed August 7 and 14, 2026. A review of current physician orders for Resident 5 revealed an order dated November 20, 2025, for staff to apply preventative barrier cream for skin incontinence care to bilateral buttocks with morning and evening care. A review of Resident 5's TAR dated August 2026, revealed the treatment was not completed August 12, 13, or 14, 2026. A review of current physician orders for Resident 6 revealed an order dated July 23, 2026, for staff to apply Zinc Oxide ointment apply topically every day and evening shift for wound healing/skin protection. A review of Resident 6's TAR dated July 2026, revealed the treatment was not completed July 24, and 28, 2026. The facility failed to provide the highest practical care regarding physician ordered treatments for Residents 4, 5, and 6. The findings were reviewed with the Nursing Home Administrator on August 16, 2026, at 2:15 PM. 483.25 Quality of CarePreviously Cited 5/21/26 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview it was determined that the facility failed to serve food in a manner to prevent potential food borne illness on two of two nursing units (Ivy and Sage nursing units, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17).Findings include: Observation of the lunch meal in the Ivy nursing unit dining room on August 4, 2026, at 12:59 PM revealed Resident 5 received a vanilla Boost liquid nutritional supplement with a use by date of March 16, 2026. Interview with Employee 7 (licensed practical nurse) on the date and time of the above observation confirmed that Resident 5 received a nutritional supplement that was beyond the use by date. Interview with Employee 10 (nurse aide) on August 4, 2026, at 1:00 PM indicated that she became aware of Resident 5's expired nutritional supplement and called the kitchen to inform Employee 8 (cook) that the kitchen served an expired nutritional supplement. Observation of Resident 6's lunch meal on the Ivy nursing unit on August 4, 2026, at 1:03 PM revealed her tray included a vanilla Boost liquid nutritional supplement with a use by date of March 16, 2026. Observation of Resident 7's lunch meal on the Ivy nursing unit on August 4, 2026, at 1:04 PM revealed her tray included a vanilla Boost liquid nutritional supplement with a use by date of March 16, 2026. Interview with Employee 8 on August 4, 2026, at 1:21 PM confirmed that he received a call from the nurse aides that residents received expired Boost nutritional drinks; however, by that time, all residents had been served. Interview with Employee 5 (dietary manager) on August 4, 2026, at 1:32 PM indicated that the food supply truck was late and she instructed staff to obtain the Boost nutritional drinks from the disaster shelf for the lunch meal. Employee 5 stated that she did not verify the expiration dates on the drinks before they were distributed to residents. Employee 5 stated that approximately 14 residents received the drinks. Interview with Employees 2 (nurse aide) and 11 (nurse aide) on the Sage nursing unit on August 4, 2026, at 1:36 PM revealed that Residents 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17, received the Boost nutritional drink with their lunch meal on this date. The surveyor reviewed the above findings related to the expired nutritional drinks during an interview with the Nursing Home Administrator and the Director of Nursing on August 4, 2026, at 3:45 PM. 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-SanitaryPreviously cited deficiency 5/21/26 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation and staff interview it was determined that the facility failed to ensure an environment free from potential accident hazards on one of two nursing units (Ivy nursing unit, Resident 18).Findings include: Interview with Employee 1 (maintenance director) on August 4, 2026, at 9:30 AM revealed that he was asked to replace a door alarm that was removed by staff from an exit door in the Ivy nursing unit dining room on a Monday morning in the middle of July 2026. Interview with Employee 2 (nurse aide) on August 4, 2026, at 12:43 PM revealed that Resident 18's husband left a dog in his car while he visited with Resident 18 on a hot day in the middle of July 2026. She and Employee 3 (nurse aide) were walking out while Employee 4 (registered nurse) heard that the dog was outside. Employee 4 went outside, retrieved the dog, and brought the dog inside the facility. At one point, the dog was in the Ivy nursing unit dining room and the alarm on the door to exit to an enclosed courtyard was sounding. She was unclear regarding what staff attempted to shut the alarm off with a key kept on the supervisor's lanyard; however, she believed that the key got stuck and staff removed the alarm box from the door and put the alarm box on the counter in the Sage nursing unit's nurses' station. Employee 2 stated that she was questioned by Employee 9 (previous nursing home administrator) and provided a statement and that, there is an investigation somewhere. Interview with Employee 3 (nurse aide) on August 4, 2026, at 12:52 PM reiterated that Resident 18's husband left a dog in his car while he visited with Resident 18 on a Sunday in July before he was walked out due to an abuse allegation involving his wife. Employee 3 reiterated that Employee 4 brought the dog into the facility and took the dog to Resident 18's husband. Employee 3 stated that she heard the door alarm from the Ivy dining room and witnessed Resident 18's husband in the courtyard with the dog. She stated that she was told that another nurse aide removed the alarm from the door. She stated that she found the alarm, sounding, on a table in the dining room covered by a pillow. She stated that she was asked to turn the alarm off and attempted to with keys found on a blue lanyard; however, she was unsuccessful, so she gave the alarm to Employee 4 at the Sage nursing unit to turn the alarm off and replace the alarm on the Ivy dining room door. The next morning, she saw that the alarm was still at the Sage nurses' station, opened up, and not sounding. Employee 3 indicated that the door in the Ivy nursing unit's dining room remained unsecured and unmonitored from the removal of the alarm on dayshift until replaced the next day on dayshift. Observation of the Ivy nursing unit dining room door with Employee 3 on the date and time of the above interview revealed a silver box mounted to the top of the door with a key lock mechanism. The door led to an open courtyard boarded on all sides by the facility building. Clinical record review for Resident 18 revealed nursing documentation dated July 14, 2026, at 1:00 PM that staff witnessed Resident 18's husband standing on the side of the bed, facing Resident 18, with his pants unzipped and his front side facing the resident's face. Resident 18 was removed immediately from the room and Resident 18's husband exited the building. Resident 18's physician, local law enforcement, Pennsylvania Department of Aging, and the Area Agency on Aging were made aware. As a part of the investigation process, the husband was limited from visitation until the investigation was concluded. Interview with Employee 4 on August 4, 2026, at 1:15 PM revealed that she confirmed that she retrieved a dog from Resident 18's husband's car with two other staff; however, she could not recall which two staff were with her. Employee 4 denied knowledge of the removal of an alarm, denied shutting an alarm off, and denied knowledge that there was an alarm box on the Sage unit's nursing station. Employee 4 confirmed that she had a blue lanyard of keys that included a key to turn off alarm boxes mounted on exit doors. Reinterview of Employee 1 on August 4, 2026, at 2:23 PM confirmed that the alarm boxes can be removed, with some effort, from the exit doors. Employee 1 stated that on a Monday morning in the middle of July, Employee 6 (licensed practical nurse) brought an alarm box to his office to make him aware that it was not on the Ivy nursing unit's dining room door; no other staff reported the missing alarm. The alarm box was opened with the battery removed. Employee 1 stated that he and Employee 9 went to the nursing unit and spoke to Employee 3 who reported that another nurse aide removed the alarm box. Employee 1 stated that Employee 3 reported that Employee 4 was given the alarm box to turn off the alarm with a key. Employee 1 stated that Employee 9 instructed him to replace the alarm on the Ivy nursing unit dining room door. The surveyor requested the facility's investigation of the exit door alarm removal during interviews with the Nursing Home Administrator on August 4, 2026, at 2:00 PM, 2:50 PM, 3:02 PM, and 3:45 PM. The Nursing Home Administrator stated that he began his position in the facility less than one week ago (July 29, 2026) and that he attempted to contact the previous Nursing Home Administrator; however, he was unable to locate any investigation, witness statements, or staff education related to the security of the Ivy dining room exit door or the prohibition of alarm removals. The facility was unable to provide evidence that any measures were implemented to ensure that no vulnerable residents could exit the Ivy dining room exit door unsupervised while the door alarm was dismantled. The facility was unable to provide evidence of corrective measures to ensure that no staff removed exit door alarms meant to protect resident safety after the above evidenced incident. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devicesPreviously cited deficiency 5/21/26 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies incidents of potential resident physical abuse for one of 10 residents reviewed (Resident 1). Findings include: The current facility policy entitled Abuse Policy, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of source shall be promptly reported to local, state, and federal agencies (as defined by current regulations), and thoroughly investigated by the administrator or designee. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) and suspicion of a crime resulting in bodily injury will be reported immediately, but not later than two hours if the alleged violation involves abuse or resulted in serious bodily injury, or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Clinical record review revealed the facility admitted Resident 1 on January 3, 2026. Nursing documentation dated May 31, 2026, at 11:25 AM revealed a licensed practical nurse on Sage nursing unit requested the registered nurse assess Resident 1's wrist. The registered nurse noted Resident 1 had two large bruises on her right wrist. Resident 1's right forearm bruise measures three centimeters by six and a half centimeters, and the bruise on her right wrist measured four and a half centimeters by nine centimeters, and purple in color. Review of the facility investigation revealed a statement from Resident 1 noting Employee 1 (nurse aide) came to change her in the morning on May 29, 2026, and threw the covers off her and grabbed her arm when she rolled her over. Resident 1 noted she screamed because it hurt. Review of Employee 1's statement revealed she denied using Resident 1's arm to roll her, Employee 1 stated she uses residents' shoulders and backs. The facility failed to report to the above alleged incident to appropriate authorities to rule out potential physical abuse or neglect. Interview with the Nursing Home Administrator and Director of Nursing on July 7, 2026, at 1:30 PM confirmed the above findings for Resident 1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and one of two nursing units (Sage). Findings include: An observation in the facility's main kitchen on May 18, 2026, at 10:15 AM with Employee 19, kitchen manager, revealed the following: The refrigerator referred to as the cook's fridge had a container of onions and peppers, tomato soup, and a turkey roast that were dated May 11, 2026. A rack containing loaves of bread and bags of buns had no receive date or expiration date on the bags. Employee 19 confirmed that the bags had been removed from the freezer but had not been dated. The dishwasher unit had a metal box located under the unit that Employee 19 believed was a contained heating element which had a thermal tape coating noted to be bubbling and peeling from around the unit. An observation on May 20, 2026, at 9:15 AM of the panty located on Sage unit revealed the following: The counter around the sink had areas of dried brown liquid, and the left side of the wooden cupboard containing the sink was bulging, and the finish appeared to be rippled from contact with water. The wall above the sink had a dried brown and a dried red splashed substance noted near the ceiling. The condiment tray had an open container of sugar free breakfast syrup with a saturated pepper packet stuck to it and crystalized syrup noted in the condiment tray. The refrigerator had a bag of grapes dated May 9, 2026, that contained grapes that were brown and wrinkled. The top of the refrigerator was covered in dust. The ice machine drainage tube was looped and contained a black substance visible through the clear tubing. The end of the tube appeared to enter a red container, and no drain or air gap could be visualized. Behind the ice machine was a Styrofoam cup full of water from what appeared to be a water leak in a tube behind the machine. The cup was sitting on two wooden pieces of two by four which ran along the wall and appeared to be wet. A plastic spoon and a plastic lid were visible under the ice machine. The above information was reviewed with the Nursing Home Administrator on May 21, 2026, at 12:00 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 7/3/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were offered the COVID-19 immunization unless contraindicated for four of five residents reviewed for immunizations (Residents 5, 22, 30, and 54); and failed to maintain documentation related to staff COVID-19 vaccination status.Findings include: The facility policy entitled, Coronavirus Disease (COVID-19), Infection Prevention and Control Measures, last reviewed without changes on April 1, 2026, indicated that the facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. The measures include encouraging staff, residents, and visitors to remain up to date with all COVID-19 vaccine doses, providing resources, and counseling about the importance of receiving the COVID-19 vaccine. Facility policies provided did not indicate that the facility would maintain documentation related to staff COVID-19 vaccination status. Interview with the Director of Nursing on May 20, 2026, at 3:27 PM and May 21, 2026, at 11:08 AM revealed that the facility had no evidence of facility documentation regarding staff COVID-19 immunization status. The interview indicated that, upon hire, staff are asked to provide an immunization card, or other documentation, regarding COVID-19 immunizations; however, the facility had no practice of offering or documenting staff COVID-19 immunizations after that time. Clinical record review for Resident 5 revealed that the facility admitted him on November 6, 2024. A COVID-19 Booster Consent or Refusal form signed on October 20, 2025, indicated that Resident 5's daughter gave verbal permission for him to receive the COVID-19 vaccine. Resident 5's clinical record did not contain evidence that he received a COVID-19 vaccine. Clinical record review for Resident 22 revealed that the facility admitted her on July 29, 2020. Review of Resident 22's immunization record revealed that the facility administered a COVID-19 vaccine on August 2, 2024. A COVID-19 Booster Consent or Refusal dated October 20, 2025, indicated that Resident 22's daughter gave verbal permission for her to receive the COVID-19 vaccine. Resident 22's clinical record did not contain evidence that she received a COVID-19 vaccine after August 2024. Clinical record review for Resident 30 revealed that the facility admitted him on March 28, 2025. A COVID-19 Booster Consent or Refusal form dated October 20, 2025, indicated that Resident 30's daughter gave verbal permission for him to receive the COVID-19 vaccine. Resident 30's clinical record did not contain evidence that he received a COVID-19 immunization. Clinical record review for Resident 54 revealed that the facility admitted her on August 22, 2024. A COVID-19 Booster Consent or Refusal form dated October 20, 2025, indicated that Resident 54 consented to receive the COVID-19 vaccine. Resident 54's clinical record did not contain evidence that she received a COVID-19 immunization. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions for three of 18 residents reviewed (Residents 3, 5, and 30). Findings include: Clinical record review for Resident 30 revealed an active physician order dated February 6, 2026, for Resident 30 to wear tubigrips (elastic tubular bandage designed to provide moderate compression and support to reduce swelling in limbs) to his bilateral lower extremities every day. Review of Resident 30's plans of care developed by the facility to address his care needs revealed no intervention that included the use of tubigrips daily to his bilateral lower extremities. Review of Resident 30's MAR/TAR (Medication Administration Record/Treatment Administration Record, electronic documentation completed by licensed nursing staff for the completion of care) dated May 2026 revealed that staff initialed the application of the tubigrips in the morning. Observation of Resident 30 on May 19, 2026, at 10:22 AM revealed that his bilateral lower legs and ankles were swollen and he did not have any compression garments in place to his legs. Interview with Resident 30 on the date and time of the observation indicated that he did not know if he was to wear compression garments on his legs. Observation of Resident 30 on May 21, 2026, at 9:40 AM with Employee 1 (licensed practical nurse) revealed that Resident 30 did not have tubigrips on his bilateral lower extremities; and his lower legs and ankles presented with swelling. Resident 30 stated he was not wearing any compression on his lower extremities because, I didn't get them yet. The surveyor reviewed the above concerns regarding Resident 30's physician ordered tubigrips during an interview with the Nursing Home Administrator and the Director of Nursing on May 21, 2026, at 11:08 AM. Observation of Resident 5 on May 18, 2026, at 12:23 PM revealed that his bilateral lower extremities presented with ace wraps that were intact on his left lower extremity but were unwinding and rolled on his right lower extremity. Interview with Resident 5 on the date and time of the observation revealed that he reported that staff do not remove the ace wraps daily. Resident 5 could not report when staff last removed his ace wraps. Documentation by the facility's contracted podiatry provider dated February 5, 2026, and April 7, 2026, noted that Resident 5 had absent dorsalis (top of the foot) and posterior tibial (behind and slightly below the ankle bone) pulses and nail thickening on both feet. The documentation dated April 7, 2026, noted that Resident 5 had a callus (thickened/hardened skin), dry skin, and lower extremity edema (swelling). The documentation included, consult with PCP (primary care physician) regarding diuretics (medication used to rid the body of excess fluids) and compression therapy to reduce LE (lower extremity) edema in an attempt to prevent skin breakdown. Clinical record review for Resident 5 revealed no physician order for the use of ace wraps to his bilateral lower extremities. Review of a plan of care initiated by the facility on July 1, 2025, identified that Resident 5 had pain and decreased circulation related to a diagnosis of peripheral vascular disease (a condition characterized by narrowing, blockage, or spasming of blood vessels most commonly affecting the legs). The plan of care did not include the application of ace wraps to his legs. The surveyor reviewed the above concern that Resident 5 had bilateral lower extremity ace wraps in place without a physician's order during an interview with the Nursing Home Administrator and the Director of Nursing on May 19, 2026, at 3:00 PM. Clinical record review revealed the facility admitted Resident 3 on September 3, 2025, with diagnosis including chronic congestive heart failure and chronic kidney disease. A physician order dated October 22, 2025, revealed Resident 3 was ordered to be on a 1500 milliliter (ml) fluid restriction every 24 hours as follows: dietary department 1080 ml on meal trays (breakfast 360 ml, lunch 360 ml, and dinner 360 ml), and nursing department 420 ml (first shift 180 ml, second shift 150 ml, and night shift 90 ml) and staff are to document all fluid intakes in point of care (POC) fluid intake task. During an interview with Resident 3 on May 18, 2026, at 11:47 AM he stated that he is on a fluid restriction. Observation of Resident 3's room at this time revealed he had four cases of water on the floor beside his recliner; two empty plastic water bottles were observed in his trash can. Further observation and interview with Resident 3 on May 21, 2026, at 11:46 AM revealed two empty soda bottles, and an empty white Styrofoam cup on his overbed table. Resident 3 stated that he gets cases of water delivered and staff do not monitor the amount of personal water he drinks daily. Review of POC documentation of Resident 3's fluid intakes from May 18 to 20, 2026, revealed the following totals:May 18, 2026- 1950 cc/mlMay 19, 2026- 1920 cc/mlMay 20, 2026- 1800 cc/ml Review of Resident 3's most recent nutritional risk assessment dated [DATE], confirmed he is ordered a 1500 mL fluid restriction, but did not address Resident 3 not complying with his fluid restriction. There was no documentation that facility staff addressed Resident 3's noncompliance with his fluid restriction, educating Resident 3 of the possible outcomes of not complying. The above findings for Resident 3 were reviewed with the Nursing Home Administrator and Director of Nursing on May 21, 2026, at 12:19 PM. 483.25 Quality of CarePreviously cited 7/3/25 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate transmission-based precautions (TBP) for two of three residents reviewed on TBP (Residents 35 and 69), failed to implement Enhanced Barrier Precautions for one of 18 residents reviewed (Resident 2), failed to implement measures to ensure hygienically cleaned laundry in the laundry department, failed to ensure an environment free from the potential spread of infection related to hand hygiene for one of 18 residents reviewed (Resident 81) and in the facility laundry department, and failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Findings include: Clinical record review for Resident 2 revealed an active physician's order dated April 29, 2026, for staff to implement Enhanced Barrier Precautions (EBP, use gown and gloves for high contact resident care including dressing, bathing, showering, transfers, hygiene care, assisted toileting, perineal care, wound care and care of any device) every shift for surgical incision. Interview with Resident 2 on May 18, 2026, at 11:44 AM revealed that he had recent back surgery and had a surgical incision on his back. Observation of Resident 2's room door on the date and time of the interview revealed a sign that alerted staff and visitors of the EBP required for the room and a yellow organizer on the door that held personal protective equipment (PPE) such as gloves and gowns. During the interaction with Resident 2, he requested that Employee 2 (licensed practical nurse) remove his surgical wound dressing for the surveyor to observe his back incision. Employee 2 obtained gloves and removed the dressing from Resident 2's back incision. Employee 2 did not don a gown before removing the dressing. Employee 2 stated that she needed to leave the room to obtain supplies to reapply the dry dressing to Resident 2's back. Employee 2 removed her gloves and performed hand hygiene, left the room, obtained dressing supplies, donned gloves, entered Resident 2's room, and reapplied a dry dressing to Resident 2's surgical wound site. Employee 2 did not don a gown for the high contact care with the surgical wound area. The surveyor reviewed the concerns regarding the implementation of EBP for Resident 2 during an interview with the Nursing Home Administrator and the Director of Nursing on May 19, 2026, at 3:00 PM. The facility policy entitled, Handwashing/Hand Hygiene, last reviewed without changes on April 1, 2026, revealed that all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand rub dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Hand hygiene is indicated after touching a resident or the resident's environment, before applying non-sterile gloves, and immediately after glove removal. Observation of a medication administration pass on May 19, 2026, at 9:08 AM revealed Employee 1 (licensed practical nurse) administer medication to Resident 81. After Employee 1 prepared the medications for Resident 81 with gloved hands, she removed her gloves, locked the medication cart, and donned new gloves. Employee 1 did not perform hand hygiene between glove changes. After Resident 81 took his medication on May 19, 2026, at 9:10 AM Employee 1 removed her gloves and began documenting the administration of medications on the medication cart computer. Employee 1 did not perform hand hygiene after removing her gloves. Interview with Employee 1 on May 19, 2026, at 9:12 AM confirmed that she had received handwashing education, but she could not recall the hand hygiene required between glove changes. The surveyor reviewed the above hand hygiene concerns during an interview with the Director of Nursing and the Nursing Home Administrator on May 19, 2026, at 3:00 PM. Observation of the facility's main laundry department on May 21, 2026, at 9:03 AM with Employee 13 (housekeeper/laundry aide) revealed that soiled resident personal laundry is sorted in the soiled laundry room and brought to another room that contained two washers and two dryers. The bags of soiled laundry are opened in front of and emptied into the washers, staff remove their gloves, leave that room, go to a bathroom in the hallway approximately 20 feet away, and wash their hands. Employee 13 stated that the sink (that was covered with a clear board) near the facility washers did not function for at least the two months that she worked in the laundry/housekeeping department. Employee 13 also stated that she was unaware of how staff ensure that the washers are not filled above their manufacturer's stated capacity to ensure appropriate agitation during processing; she did not know the load weight capacity of the washers. Employee 13 obtained assistance from her supervisor, Employee 14 (maintenance director) on May 21, 2026, at 9:19 AM, who stated that each facility washer has a weight capacity of 21.5 pounds; and that the facility had a scale to weigh soiled laundry loads before processing. Observation of the soiled laundry room with Employees 13 and 14 on May 21, 2026, at 9:22 AM revealed a laundry scale in the corner of the room that contained two brooms and a dustpan. The scale appeared unused for recent laundry processing. Interview with Employee 14 on May 21, 2026, at 9:22 AM revealed that he was not aware that the sink near the facility washers was not functioning. After the staff removed the clear board that covered the sink, it was determined that both the hot and cold-water supply worked. The surveyor reviewed the above laundry department concerns during an interview with the Nursing Home Administrator and the Director of Nursing on May 21, 2026, at 11:08 AM. The surveyor requested the facility's waterborne pathogen prevention program to mitigate waterborne illness (such as Legionella) risk during a facility entrance interview on May 18, 2026, at 10:30 AM. During an interview with the Director of Nursing and the Nursing Home Administrator on May 19, 2026, at 3:00 PM the facility provided the CDC (U.S. Centers for Disease Control and Prevention) Healthcare Facility Water Management Program Checklist that was not individualized for the facility; but was the outline suggested by CDC to follow to formulate an individualized facility water management program. Interview with Employee 14 (maintenance director) and the Nursing Home Administrator on May 20, 2026, at 9:00 AM revealed that the facility reported they had no water holding tanks and that city water entered the building and to hot water heaters directly. The facility did not provide a schematic of the building that identified potential problem areas or a waterborne pathogen prevention program that included identified risks, control measures to prevent growth of pathogens, protocols to monitor the measures, acceptable monitoring outcomes, and established methods to intervene when control measures are not met. Interview with Employee 14 on May 20, 2026, at 11:55 AM revealed that the available facility Legionella Surveillance and Detection and Legionella Water Management Program policies indicate that areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria include water storage tanks, water heaters, filters, fountains, etc.; however, the program did not stipulate specific measures to control the introduction and/or spread of Legionella, the control limits that are acceptable and are monitored, or a plan for when control limits are not met or effective. The facility failed to develop and implement measures to minimize the risk of Legionella and other opportunistic pathogens in the building's water systems through a documented water management program based on nationally accepted standards. Clinical record review for Resident 69 revealed that they tested positive for MRSA (Methicillin-resistant Staphylococcus aureus, a multi-drug-resistant organism, or MDRO) to an open area located on their abdomen and was subsequently placed on contact precautions (additional infection control measures used to prevent the spread of infectious diseases, also referred to as Transmission Based Precautions or TBP), by the provider on May 11, 2026. Observation of Resident 69's room on May 18, 2026, at 11:25 AM revealed signage outside the resident's door, which indicated contact precautions were in place for the room, and everyone must clean hands before entering and when exiting the room, and all staff and providers must wear a gown and gloves before entering the room, and remove them before exiting. Supplies including gowns and gloves were noted to be hanging on the door. Observation on May 18, 2026, at 11:55 AM revealed Employee 16, nurse aide, deliver Resident 69's meal tray without putting on gloves or a gown. Clinical record review for Resident 35 revealed a diagnosis for Clostridium Difficile (a bacterial infection, also referred to as C. Difficile) entered on April 1, 2026. Further review revealed the resident was on contact precautions. Facility Policy titled Clostridioides (Clostridium) Difficile last updated on April 1, 2026, revealed that it is the facility policy to implement steps toward prevention and early intervention which include frequent hand washing with soap and water by staff and residents, wearing gloves and a gown when caring for residents with potential infectious diarrheas, or when handling feces or articles contaminated with feces. Observation of Resident 35's room on May 18, 2026, at 3:00 PM revealed signage outside the resident's door, which indicated contact precautions were in place for the room, everyone must clean hands before entering and when exiting the room, and all staff and providers must wear a gown and gloves before entering the room and remove them before exiting. Supplies including gowns and gloves were noted to be hanging on the door. The door to the room was open with a privacy curtain pulled around the resident. Employee 7, registered nurse, was observed in the room providing care for Resident 35. Employee 7 was observed exiting the room with gloves on their hands holding unbagged laundry in their right hand, and a handful of supplies in their left hand, which appeared to be prefilled syringes. Employee 7 took the dirty laundry to the dirty linen room across from the nursing station on Ivy unit and then placed the handful of supplies on the nursing counter while speaking with other staff. Employee 7 then returned to Resident 35's room with the supplies and entered the room without washing hands or applying a gown and clean gloves. Employee 7 continued to provide care for Resident 35, while Employee 8, nurse aide, entered the room to assist Employee 7. Employee 8 was not observed washing their hands and did not put on a gown before entering the room. At 3:15 PM, Employee 7 exited the room without washing hands. Employee 7, with gloves remaining on hands, was holding pillowcases and two pillows that were not in a plastic bag and took them to the dirty linen room. At this time, Employee 7 was heard requesting a Hoyer Lift (a specific style of lift that is used to transfer patients with limited mobility from one location to another). Employee 7 then entered Resident 35's room again and did not wash their hands or put a gown or clean gloves on. At 3:25 PM Employee 9, nurse aide, entered Resident 35's room with a Hoyer Lift and was observed taking it to resident 35's bedside. Employee 9 did not put on a gown or gloves prior to entering the resident's room. At this, employee 9 then closed Resident 35's door. The Nursing Home administrator and the director of nursing were made aware of the above concerns related to Resident 69 and Resident 35 on May 19, 2026, at 3:00 PM. Observation on May 21, 2026, at 11:05 AM, revealed that there was no garbage disposal bin for gloves or gowns when exiting Resident 35's room. Employee 1, licensed practical nurse, and Employee 11, nurse aide, stated that the gowns and gloves were just being disposed of in the resident's personal trash bins. Employee 1, and Employee 11 stated that to their knowledge there have never been any trash bins to dispose of gowns gloves, or linens located in the room. During an interview on May 21, 2026, at 11:35 AM with the Nursing Home Administrator and the Director of Nursing, the Director of Nursing indicated that they did have a shortage of disposal bins. 483.80 Infection ControlPreviously cited deficiency 7/3/25 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)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regimen review (Residents 2 and 10). Findings include: The facility policy entitled, Psychotropic Medication Use, last reviewed without changes on April 1, 2026, revealed that medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics, antidepressants, antianxiety medications; and hypnotic/sedatives. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: determining adequate indications for use, adequate monitoring for efficacy and adverse consequences, determining appropriateness of gradual dose reductions, and preventing/identifying/responding to adverse consequences. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's: physical, behavioral, mental, and psychosocial status; expressions or indications of distress; and resident behaviors and symptoms. Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist. In addition, residents are monitored for adverse consequences associated with psychotropic medications. Clinical record review for Resident 2 revealed that the facility admitted him on July 10, 2025. A review of his medication regime revealed revisions of his physician's orders for the use of the antidepressant, Fluoxetine (Prozac): Fluoxetine 40 mg (milligrams) one time a day for depression, discontinued August 5, 2025Fluoxetine 20 mg one time a day for depression from August 6, 2025, to September 9, 2025Fluoxetine 40 mg one time a day for depression from September 10, 2025, to February 16, 2026Fluoxetine 60 mg one time a day for depression from February 17, 2026 to April 8, 2026Fluoxetine 40 mg one time a day for depression from April 9, 2026, to the dates of the onsite visit beginning May 18, 2026 Physician progress note documentation dated March 3, 2026, at 10:48 AM revealed that Resident 2 stated that he had a tremor that sometimes limits his ability to shave and hold his cup. The documentation indicated that Resident 2's Fluoxetine dose increased to 60 mg per the contracted psych provider (Resident 2 previously was prescribed 20 mg). Nursing documentation dated March 16, 2026, at 12:56 PM revealed that the contracted psych nurse practitioner assessed Resident 2 for anxiety and depression and recommended to continue the current dose of Prozac (Fluoxetine). Physician progress note documentation dated April 2, 2026, at 10:21 AM revealed that Resident 2 stated that he had a tremor that sometimes limits his ability to shave and hold his cup and that communication to the contracted psych provider questioned if Resident 2's Fluoxetine could be reduced in view of the reported increased tremor. Progress note documentation by the facility's contracted psychiatry provider dated April 6, 2026, confirmed that there was a concern noted about an increase in Resident 2's tremors and that it may be related to the Prozac titration or his Gabapentin (Neurontin, medication used to treat the symptoms of neuropathy/abnormal sensations or pain from nerve damage). Prozac was titrated from 40 mg to 60 mg on a February 9, 2026, visit. Resident 2 was agreeable to go back to the 40 mg dose to reduce the chance of tremors returning. The provider indicated that Resident 2, .seems he likes things a certain way and when this doesn't happen, he becomes passive aggressive in a sense. Social services documentation dated April 28, 2026, at 11:25 AM revealed that Resident 2 had a PHQ-9 (scoring system that ranges from zero to 27, with higher scores indicating more severe depression symptoms) severity score of 24, indicating severe depression. He also related that he felt that he would be better off dead every day. Resident 2 reported that he felt, extra depressed, due to a recent fall, fracture, surgery, and hospitalization. He had a significant history for depression and anxiety and received Fluoxetine and is followed by psych services for medication management. Social services would continue to follow for psychosocial needs. Social services documentation dated April 28, 2026, at 12:42 PM indicated that Resident 2's PHQ-9 severity score was 27, not 24. Physician progress note documentation dated May 18, 2026, at 10:57 AM revealed that Resident 2 stated that he had a tremor and that communication to the contracted psych provider questioned if Resident 2's Fluoxetine could be reduced in view of the reported increased tremor. Review of a plan of care developed by the facility (initiated July 21, 2025) to address Resident 2's risk for alteration in mood state related to admission and history of depression and anxiety revealed interventions that included to, Observe for/document/report to MD s/sx (signs and symptoms) of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Interview with the Nursing Home Administrator and Director of Nursing on May 21, 2026, at 8:15 AM revealed that staff document ongoing monitoring of negative behaviors and potential medication adverse side effects on the MAR/TAR (medication administration record/treatment administration record, electronic documentation by licensed staff). Review of Resident 2's MAR/TAR dated March, April, and May 2026 revealed no ongoing monitoring of negative behaviors related to his depression diagnosis or potential adverse side effects from the use of the antidepressant medication. Resident 2's medication regimen included the use of an antidepressant without adequate monitoring of behavioral symptoms and potential adverse side effects. Clinical record review revealed the facility admitted Resident 10 on November 7, 2024. Review of Resident 10's active physician orders revealed staff are to administer the following psychotropic medications: Sertraline HCl (an antidepressant medication) 100 mg, one tablet every evening and night shift.Sertraline HCl 25 mg, one tablet at bedtime.Trazodone HCl (an antidepressant medication) 50 mg, one tablet every evening.Risperdal (an antipsychotic medication) 3 mg, two times a day. The facility-initiated behavior monitoring November 7, 2024, combining Resident 10's behaviors of anxiety and aggressiveness. Review of Resident 10's MAR/TAR dated March, April, and May 2026 revealed no ongoing monitoring of negative behaviors related to her depression diagnosis. Resident 10's medication regimen included the use of antipsychotic and antidepressant medications without adequate monitoring of behavioral symptoms. The above findings for Resident 10 were confirmed with the Director of Nursing on May 20, 2026, at 10:46 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were offered the pneumococcal immunization unless contraindicated for three of five residents reviewed for immunizations (Residents 22, 30, and 54).Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on April 1, 2026, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and, when indicated, will be offered the vaccine series within 30 days of admission unless medically contraindicated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Current CDC website information notes that there are four pneumococcal vaccines available in the United States. Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20 (Prevnar20), and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). Each of these vaccines helps protect against specific serotypes, or strains, of pneumococcal bacteria. The number at the end of the vaccine name tells how many strains the vaccine includes. CDC Pneumococcal Vaccine Timing for Adults (https://www-new.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf) instructs that a complete series would be a PCV13 (Prevnar 13, pneumococcal conjugate vaccine) at any age, a PPSV23 (Pneumovax 23, pneumococcal polysaccharide vaccine) at greater than or equal to 65 years, and together with the resident, vaccine providers may choose to administer PCV20 (Prevnar 20, 20-valent pneumococcal conjugate vaccine) or PCV21 (CAPVAXIVE, 21-valent conjugate vaccine) to adults greater than or equal to [AGE] years old who have already received the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The CDC stipulates that, Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Current CDC information indicates that for someone greater than [AGE] years old, with no known prior pneumococcal vaccines, the first option is to administer the PCV20 or PCV21; and the second option is to administer the PCV15 followed by the PPSV23 after greater than one year. Clinical record review for Resident 30 revealed that the facility admitted him on March 28, 2025, when he was [AGE] years old. Review of Resident 30's immunization history revealed that he received the Prevnar13 before his admission to the facility on October 9, 2015, when he would have been [AGE] years old. Resident 30's clinical record contained no evidence that he received any additional pneumococcal vaccinations in the more than 10 years since his last immunization. Review of a Pneumococcal Immunization Consent/Declination dated October 20, 2025, revealed that Resident 30's daughter consented to Resident 30's pneumococcal vaccine. Per CDC guidelines, Resident 30 should have received either the PCV20 or PCV21 immunization. Clinical record review for Resident 54 revealed that the facility admitted her on August 22, 2024, when she was [AGE] years old. Review of a Pneumococcal Immunization Consent/Declination dated October 20, 2025, revealed that Resident 54 consented to pneumococcal immunization. Review of Resident 54's immunization history revealed no evidence that she received pneumococcal immunizations before her admission to the facility. Resident 54's immunization documentation indicated that the facility administered the PPSV23 immunization on October 30, 2025. Per CDC guidelines, the facility should have administered the PCV15, PCV20, or PCV21 immunization to Resident 54. Clinical record review for Resident 22 revealed that the facility admitted her on July 29, 2020, when she was [AGE] years old. Review of a Pneumococcal Immunization Consent/Declination dated October 20, 2025, revealed that Resident 22's daughter consented to pneumococcal immunization. Review of Resident 22's immunization documentation indicated that Resident 22 received the Prevnar13 vaccine on February 10, 2020, and the PPSV23 vaccine on February 19, 2021. Resident 22's immunization documentation indicated that Resident 22 did not receive the PCV20 immunization because she was not eligible on February 5, 2025. Per CDC guidelines, Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Based on Resident 22's immunization history and CDC guidelines, Resident 22 would have been eligible for a pneumococcal immunization in February 2026, however, there was no evidence that the facility offered Resident 22 pneumococcal revaccinations when she became eligible. Interview with the Director of Nursing on May 21, 2026, at 11:08 AM confirmed the above findings regarding pneumococcal immunizations for Residents 22, 30, and 54. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of two residents reviewed (Residents 10 and 74).Findings include: Clinical record review for Resident 74 revealed the facility admitted her on August 27, 2025, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 74's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated August 29, 2025, indicated that the facility assessed Resident 74 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 74's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 10 revealed the facility admitted her on November 7, 2024, with diagnosis including dementia. Review of Resident 10's annual MDS dated [DATE], indicated that the facility assessed Resident 10 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 10's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview with Employee 15 (social worker) on May 20, 2026, at 9:02 AM confirmed these findings. The findings were reviewed with the Director of Nursing on May 21, 2026, at 11:50 AM, and she was unable to provide any further documentation indicating the facility developed and implemented individualized person-centered care plans to address Residents 10 and 74's dementia and cognitive loss 28 Pa Code 211.12 (d)(1)(3)(5) Nursing service

Based on clinical record review and staff interview it was determined that the facility failed to ensure that an assessment accurately reflected a resident's status for one of 18 residents reviewed (Resident 2).Findings include: Clinical record review for Resident 2 revealed nursing documentation dated April 22, 2026, at 3:08 PM that Resident 2 was on the floor. Resident 2 complained of mid back pain. Nursing documentation dated April 22, 2026, at 6:40 PM revealed that Resident 2 insisted on going to the emergency room due to back pain and 911 (emergency personnel) transported Resident 2 to the emergency room. Nursing documentation dated April 23, 2026, at 10:57 AM revealed that the writer called the hospital and obtained information that Resident 2 was admitted for vertebral (spinal) fractures for which he was going to have surgery. A Discharge MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 22, 2026, assessed that Resident 2 had a fall with an injury that was not coded as a major injury. The facility staff signed the assessment section on April 24, 2026, at 5:02 PM. Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual (RAI, MDS) instructions to complete Section J related to falls instructs that the definition for injury (except major) related to a fall includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. Major injury includes, but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries. Hospital Discharge Summary documentation for Resident 2's hospitalization from April 22, 2026, to April 27, 2026, noted that his principal diagnosis was fall with a T7-T8 (thoracic bones seven and eight) unstable fracture for which he underwent surgery. The surveyor confirmed the above MDS assessment injury coding error with the Nursing Home Administrator on May 20, 2026, at 11:38 AM. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two of three residents reviewed (Resident 8 and 25).Findings include: During an interview with Resident 8 on May 19, 2026, at 9:13 AM the resident stated she frequently prefers to keep her door closed and that staff often do not knock on her door before entering. During the interview, Employee 18, housekeeping, was observed entering Resident 8's room, opening the closed door without knocking and delivering laundry. After Employee 18 exited the room, Resident 8 indicated, See? They never knock. The facility failed to ensure residents' dignity related to valuing residents' private space. Clinical record review for resident 25 revealed a physician order dated November 11, 2025, for care of nephrostomy tubes (a thin catheter that drains urine from your kidney into an external bag). Observations on May 19, 2026, at 11:25 AM revealed Resident 25 sitting in a chair across from the nurse's station on Sage unit with a urinary catheter bag (a collection device connect to a catheter to hold urine) resting on their lap and appearing to be half full of yellow liquid. Observation on May 19, 2026, at 11:55 AM revealed staff standing Resident 25 up and clipping the urine bag to the outside of the resident's pants in order to assist the resident with ambulating the resident to the dining room. Observation on May 19, 2026, at 12:00 PM revealed Resident 25 sitting in the dining room with urine bags wrapped around the front arm support of their chair while the resident ate their lunch. The resident was then observed on May 19, 2026, at 12:23 PM ambulating down the hallway with two urine bags, one clipped to each side of their shirt, both filled with yellow liquid. The facility failed to ensure a resident's dignity related to leaving urinary catheter bags uncovered. The above concerns related to Resident 8 and Resident 25 were discussed with the Nursing Home Administrator and the Director of Nursing on May 19, 2026, at 3:00 PM. 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 18 residents reviewed (Resident 3).Findings include: The policy entitled Self-Administration of Medications, revealed residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, it is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and /or decision-making status. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart, or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge. Clinical record review revealed the facility admitted Resident 3 on September 3, 2025. Further review of Resident 3's clinical record revealed a physician order-initiated April 9, 2026, for staff to administer Voltaren Arthritis Pain External Gel (a topical ointment for pain relief), and to apply to Resident 3's right elbow, shoulder, and left hand topically two times a day for pain. Observation of Resident 3 on May 18, 2026, at 11:28 AM, revealed Resident 3 was at the nurses' station when Employee 10 (licensed practical nurse) handed Resident 3 a souffle cup with an unidentified white substance in it. Resident 3 proceeded to carry the souffle cup to his room. Observation and interview with Resident 3 on May 18, 2026, at 11:49 AM revealed the souffle cup with the white substance was on Resident 3's over bed table. Resident 3 stated that the substance in the souffle cup was his physician ordered Voltaren gel. He stated Employee 3 gave it to him for his shoulder pain. Resident 3 stated he would put it on his shoulder later. Further review of Resident 3's clinical record revealed no evidence of an assessment for Resident 3 to self-administer her medications. Interview with the Nursing Home Administrator and Director of Nursing on May 21, 2026, at 8:31 AM, confirmed the facility did not assess Resident 3's capability to self-administer his Voltaren gel. The Director of Nursing revealed that a Medication Self-Administration Screen was completed on May 20, 2026, after the surveyor's questioning and Resident 3 was deemed unable to safely administer his medications. The facility failed to determine Resident 3's capability to self-administer his medications. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review and resident, family, and staff interviews it was determined that the facility failed to ensure the resident or resident's responsible party received a personal fund statement quarterly for two of two residents reviewed for personal funds concerns (Residents 6 and 22).Findings include: Interview with Resident 22's daughter on May 18, 2026, at 2:14 PM indicated that the facility holds money for her mother, however, she did not receive a quarterly statement. Resident 22's daughter confirmed that her mother lacks the cognitive capacity to manage her own financial affairs. Clinical record review for Resident 22 revealed profile information that listed her daughter as her financial and healthcare power-of-attorney (POA), substitute decision-maker, and resident representative. Quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated January 21, 2026, and March 24, 2026, assessed Resident 22 as rarely or never understood, with long- and short-term memory problems, and severely impaired cognitive skills for decision making. The handwritten notation on Resident 22's resident fund statement dated for the quarter January 1, 2026, through March 31, 2026, read, gets own did not send to POA. Interview with Employee 4 (business office manager) on May 20, 2026, at 10:59 AM confirmed that Resident 22's responsible party did not receive a resident fund statement; and that Resident 22 has cognitive deficits that prevent her comprehension of the financial record. Interview with Resident 6 on May 18, 2026, at 1:58 PM revealed that the facility business office staff hold money for her, however, she does not receive a statement at least quarterly. Resident 6 stated that she did not know who received the statement. On May 19, 2026, at 9:45 AM Resident 6 stopped the surveyor in the hallway to report again that she did not know who received her quarterly personal fund statement. Clinical record review for Resident 6 revealed that the facility admitted her on June 17, 2020. A quarterly MDS assessment dated [DATE], noted her BIMS (Brief Interview for Mental Status, short standardized cognitive screening tool that numerically scores question responses) score was 15 that indicated she had no cognitive impairments. Interview with Employee 4 on May 20, 2026, at 10:59 AM revealed that she prints quarterly statements and puts them in the activity box for Employee 3 (activities director) to deliver to residents. Interview with Employee 3 on May 20, 2026, at 11:01 AM indicated that she hand-delivers the statements that are in her box, however, she could not recall what residents get statements. She could not recall if she delivered a resident fund statement to Resident 6. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Ivy unit and Residents 8 and 39).Findings include: Observation of Resident 8's room on May 18, 2026, at 1:05 PM revealed strong urine-like odor, and a pile of linens in a soiled linen bag with some linens noted on top of the bag. Concurrent interview with the resident revealed that she is incontinent of bladder and frequently urinates on the floor, then cleans it independently and puts the soiled linens on the floor to be collected later. During resident interview, Employee 18, housekeeping, was observed entering the residents' room and stating, The floor is not as sticky today. Observation of Resident 8's room on May 19, 2026, at 11:38 AM revealed that the room continues to have a strong urine-like odor, and the floor remained sticky underfoot. Observation of Resident 39's bathroom on May 19, 2026, at 10:07 AM revealed that the floor was sticky underfoot. The counter behind the faucet was yellow and appeared stained. Concurrent interview with Resident 39 revealed that housekeeping cleans the bathrooms about once a week. Observation on May 20, 2026, at 10:45 AM of the wall across from the nursing station on Ivy unit revealed that the paint from the handrails along this wall was scrapped off, revealing bare metal. The above concerns were reviewed with the nursing home administrator and the director of nursing on May 20, 2026, at 12:30 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 7/3/2025, and 10/30/25 28 Pa. Code 201.18(b)(3) Management

Based on clinical record review and staff interview it was determined that the facility failed to ensure resident representative contact information was communicated to the receiving health care institution for one of four residents reviewed for hospitalization concerns (Resident 2).Findings include: Clinical record review for Resident 2 revealed nursing documentation dated April 22, 2026, at 6:40 PM that Resident 2 wanted to go to the emergency room due to pain in his back. Emergency services (911) were at the facility and transported Resident 2 via a stretcher. The writer indicated that Resident 2's sister was made aware of the transfer. Review of Resident 2's clinical record profile information revealed his sister was listed as his representative. An, eINTERACT Transfer Form (document generated by the facility's electronic medical record system to ensure appropriate information is communicated to a receiving health care institution or provider), dated April 22, 2026, completed for Resident 2's discharge to the hospital, revealed that Resident 2 was listed as his own resident representative; the facility did not include the contact information for his sister who was listed in his profile information as his representative. Interview with the Director of Nursing on May 20, 2026, at 10:46 AM confirmed that the eINTERACT Transfer Form is what is used by the facility to communicate information to the receiving hospital staff; and Resident 2's transfer form did not communicate Resident 2's representative contact information for his hospitalization as noted above. 483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) Discharge ProcessPreviously cited deficiency 7/3/25 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, observation, and staff interview it was determined that the facility failed to revise a resident's plan of care for one of 18 residents reviewed (Resident 30).Findings include: Clinical record review for Resident 30 revealed an active physician's order dated February 6, 2026, that Resident 30 was to wear tubigrips (specially designed elastic bandages used to reduce swelling) to his bilateral lower extremities every day. Observation of Resident 30 on May 19, 2026, at 10:22 AM revealed that his lower legs and ankles presented with swelling and he was not wearing tubigrips. Review of Resident 30's plans of care developed by the facility to address his care needs revealed no intervention that included the use of tubigrips daily to his bilateral lower extremities. Review of Resident 30's MAR/TAR (Medication Administration Record/Treatment Administration Record, electronic documentation completed by licensed nursing staff for the completion of care) dated May 2026 revealed that staff initialed the application of the tubigrips in the morning. The surveyor reviewed the above concerns regarding Resident 30's plan of care during an interview with the Nursing Home Administrator and the Director of Nursing on May 21, 2026, at 11:08 AM. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of two residents reviewed (Resident 48).Findings include: Observation of Resident 48 on May 18, 2026, at 2:31 PM and May 19, 2026, at 12:34 PM revealed she was in bed and her hair appeared greasy. Interview with Resident 48 on May 19, 2026, at 12:34 PM revealed the resident was unable to recall when she last received a shower. Resident 48 stated she is supposed to receive a shower once a week. Clinical record review revealed the facility admitted Resident 48 on September 3, 2025. A review of Resident 22's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 27, 2026, indicated nursing staff assessed Resident 48 as dependent on staff for bathing. Review of Resident 48's plan of care-initiated September 3, 2025, revealed Resident 48 has an activity of daily living self-care performance deficit and is totally dependent on staff to provide a bath or shower weekly and as necessary. A review of Resident 48's task documentation (ADL, activities of daily living charting) revealed her preference is to receive a shower every Thursday evening. Further review revealed Resident 48's documentation survey report (electronic documentation completed by nurse aide staff for the completion of ADL care) for March, April, and May 2026, indicated Resident 48 only received four showers/baths and refused twice. There was no documentation of staff offering, or Resident 48 refusing a shower/bath from May 1 to 21, 2026. The above findings for Resident 48 were reviewed with the Nursing Home Administrator and the Director of Nursing on May 20, 2026, at 12:39 PM. Further interview with the Director of Nursing on May 21, 2026, at 9:30 AM revealed she was unable to provide further documentation that the facility provided bathing assistance for Resident 48. 28 Pa Code 211.11(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent falls for two of four residents reviewed for falls (Residents 8 and 37).Findings include: Clinical record review of Resident 37 revealed a fall without injuries occurring on February 13, 2026, in the resident's shower. The Interdisciplinary team determined that adding non-slip strips (tacky/rough material that adheres to surfaces) to the resident's shower would be an appropriate intervention, and that the care plan care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the Focus, Goal, and Interventions) would be updated to reflect this. Observation of the resident's shower on May 20, 2026, at 9:30 AM revealed no non-slip strips were present. Interview with Employee 17, nurse aide, on May 20, 2026, at 934: AM, confirmed that the resident did not have any non-slip strips present in the shower in Resident 37's room, nor were any non-slip strips installed in the shower located on the unit. During an interview with the Nursing Home Administrator on May 20, 2026, at 9:45 AM, they were made aware of the above findings and confirmed that non-skid strips are strips that would be directly adhered to the floor. Review of Resident 8's care plan initiated on November 14, 2025, revealed a Focus area that the resident was at risk for falls, and an Intervention list that included Call don't Fall sign hung in the resident's room. Observation of Resident 8's room on May 20, 2026, at 9:20 AM, revealed no sign indicating Call don't Fall hanging anywhere in the room. During an interview with the resident at this time, they stated they do not recall there ever being a sign hung in their room that stated this. Interview with Employee 1, licensed practical nurse, on May 21, 2026, at 10:55 AM, confirmed that no sign was hanging in Resident 8's room related to falls or their call bell. The above information related to Resident 8 was reviewed with the Nursing Home Administrator on May 21, 2026, at 11:35 AM. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/DevicesPreviously cited 7/3/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement care planned interventions (supervision in the bathroom) to prevent resident accidents for one of two residents reviewed for falls that caused actual harm (Resident 1). Findings include: The facility policy entitled, Fall Management Policy and Procedure, last reviewed without changes on June 18, 2021, revealed that the falls management program's goal is to prevent/reduce falls, reduce injury, and ultimately improve the quality of life for the residents and enhance the resident's sense of security and safe environment. The purpose is to limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured program interventions. Key elements to the fall management program included: Treatment plan/interventions will be individualized and include the use of devices such as protectors, room/bed modifications, etc., as appropriate. Interventions will be put into place according to individual resident needs. The charge nurse will receive and transcribe any interventions required and document on the treatment record, care plan, and closet care card appropriately. Documentation of falls and interventions will be in the medical record. Post Fall Investigations will be completed by the registered nurse supervisor utilizing the Incident/Accident Form and Fall Risk Assessment. The interdisciplinary team will review resident incidents, including falls, at morning meeting. Data and interventions will be reviewed and evaluated, and patterns and trends will be identified, and recommendations will be made. The resident care plan will reflect needs and interventions. Nursing staff education regarding falls, fall reduction, and prevention will occur at least annually and as needed as individual resident needs occur. Clinical record review for Resident 1 revealed the facility admitted her on March 22, 2019, with diagnoses including dementia. The facility identified Resident 1 as a high fall risk related to her confusion, gait, and balance problems, being unaware of safety needs, use of medications with known risk, and a history of falls. The facility initiated a plan of care on April 11, 2019. On April 22, 2021, the facility implemented an intervention of not leaving Resident 1 unattended on the toilet. Review of Resident 1's most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 10, 2022, noted nursing staff assessed Resident 1 as severely cognitively impaired and requiring extensive assistance of one staff for transfers. Further review of Resident 1's clinical record revealed physical therapy notes indicating Resident 1 received physical therapy from March 2 to 17, 2022, noting her sit to stand ability was partial to moderate assistance. Nursing documentation dated March 26, 2022, at 9:57 PM indicated that Employee 1 (registered nurse) noted Resident 1 was found on the floor in the bathroom after falling off the toilet and needed to be sent to the emergency department due to bleeding profusely from the head lacerations. This documentation was marked as incorrect documentation and the facility was unable to explain why this documentation was marked incorrect. Nursing documentation dated March 26, 2022, at 11:08 PM revealed Employee 2 (registered nurse) noted Resident 1 was found on the floor attempting to go make it to the bathroom. Further review of Resident 1's clinical record revealed documentation by Employee 1 on March 27, 2022, at 5:52 PM noting Resident 1 was found on the floor after falling off the toilet and trying to get up at 9:25 PM. Review of Resident 1's history and physical from [NAME] hospital dated March 27, 2022, revealed that Resident 1 was admitted with an odontoid (bone in neck) fracture, bilateral C1 arch (vertebral) fracture, a 3-centimeter (cm) laceration on her anterior forehead with sutures, and 2 cm laceration to the crown of her head with staples in place. Nursing documentation dated March 29, 2022, at 1:50 PM noted Resident 1 returned from [NAME] Hospital with a large abrasion on top of her forehead, eyes bruised, and a hard neck collar. Review of the facility investigation into Resident 1's March 26, 2022, fall revealed Resident 1 was found on the floor in her bathroom. The investigation noted that Resident 1 had been in her personal chair prior to the fall. Interview with Employee 3 (licensed practical nurse) on April 12, 2022, at 12:40 PM revealed she heard Resident 1's roommate yelling for help and Employee 1 stated that she found Resident 1 on the floor in the bathroom. Employee 3 stated that Resident 1 was in her personal chair prior to the fall and stated that Resident 1 is unable to transfer herself from the personal chair. Interview with Employee 4 (physical therapist aide) on April 12, 2022, at 12:55 PM revealed that Resident 1 can transfer herself from her wheelchair due to the height, but Resident 1 is unable to transfer herself from a seated position to standing from the personal chair in her room. Employee 4 confirmed that staff had to assist Resident 1 to the bathroom due to her inability to transfer herself from the personal chair. The facility investigation failed to reveal which staff member transferred Resident 1 from her recliner chair to the bathroom and left her unsupervised. The facility failed to ensure Resident 1 received adequate supervision to prevent an accident with serious injuries. Interview with the Nursing Home Administrator and Director of Nursing on April 12, 2022, at 1:38 PM confirmed these findings and were unable to provide any further documentation. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited deficiency 3/23/22 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement physician ordered bowel management protocols for four of 14 sampled residents (Residents 46, 47, CR1, and 8) resulting in a fecal impaction for one of 14 residents reviewed (Resident 46). Findings include: The facility protocol entitled, Laxative List last reviewed November 15, 2016, without changes indicates the following: 7-3 shift day 3 without a BM (bowel movement), the resident will receive 4-6 ounces of prune juice 3-11 shift day 3 without a BM, the resident will receive 5 mg (milligram) [MEDICATION NAME] tab after dinner 7-3 shift day 4 without a BM, the resident will receive [MEDICATION NAME] 10 mg suppository after breakfast 3-11 shift day 4 without a BM, the resident will receive [MEDICATION NAME] Fleet's enema after dinner prior to hour of sleep, assist resident to use the commode Day 5 if no bowel movement notify charge nurse/designee and physician for further orders An interview with the Nursing Home Administrator and the Director of Nursing on December 15, 2016, revealed that the facility had no policy regarding how staff count days of no bowel movement (e.g. via 24 hour periods between bowel movements, or via nine shifts with no bowel movement, etc.). Clinical record review for Resident 46 revealed physician's orders [REDACTED].(fluid injected into the lower bowel by way of the rectum) enema if no bowel movement eight hours after the [MEDICATION NAME] suppository. Review of the plan of care initiated by the facility on June 23, 2016, to address Resident 46's constipation related to decreased mobility, a [MEDICAL CONDITION] (nerve cells in the brain and spinal cord are damaged) diagnosis, and side effects of medication revealed that interventions included the administration of medications as ordered by the physician; and to follow the facility bowel protocol for bowel management. Review of a Bowel Output, form (form utilized by the facility to document a resident's bowel movements) dated July 2016 revealed that staff documented that Resident 46 had a bowel movement at 4:00 AM on July 10, 2016. Staff documented no bowel movements for Resident 46 on July 11, 12, 13, 14, and 15, 2016. Review of Resident 46's MAR (Medication Administration Record, [REDACTED]. The MAR indicated [REDACTED]. Nursing documentation dated July 17, 2016, at 4:17 PM revealed that, (Resident 46) was completely full of hard formed stool that was stretching her rectal vault and causing discomfort. During PM (evening) bed bath, stool was dislodged during rolling and expelled. Large amount of formed stool was noted . An interview with the Nursing Home Administrator and the Director of Nursing on December 15, 2016, at 12:00 PM confirmed that the facility had no evidence that the staff attempted to follow the physician's orders [REDACTED]. Clinical record review for Resident 47 revealed admission physician's orders [REDACTED]. if no bowel movement eight hours after the [MEDICATION NAME] suppository. Review of bowel elimination documentation for Resident 47 dated November 2016, revealed that staff documented a bowel movement on November 17, 2016, at 1:17 PM. Staff noted no bowel activity for Resident 47 on November 18, 19, and 20, 2016. The next bowel movement staff recorded for Resident 47 was on November 21, 2016, at 12:33 AM (11 shifts, more than 72 hours following the previously documented bowel movement). Review of Resident 47's MAR indicated [REDACTED]. Continued review of bowel elimination documentation for Resident 47 revealed that staff documented a bowel movement on November 30, 2016, at 9:41 PM and not again until December 4, 2016, at 10:57 AM (11 shifts, more than 84 hours following the previously documented bowel movement). Review of Resident 47's MAR indicated [REDACTED]. Closed clinical record review for Resident CR1 revealed admission physician's orders [REDACTED]. if no bowel movement eight hours after the [MEDICATION NAME] suppository. Review of a Bowel Output, record dated July 2016 revealed that the staff documented bowel activity for Resident CR1 on July 31, 2016. Review of Resident CR1's MAR indicated [REDACTED]. There was no evidence that the staff attempted prune juice before the [MEDICATION NAME]; or the rationale for implementing the physician ordered bowel protocol before the third day of no bowel activity. Review of a Bowel Output, record dated August and September 2016, revealed that the staff documented bowel activity for Resident CR1 on August 29, 2016. The staff documented no bowel activity for Resident CR1 on August 30 and 31, 2016, and September 1 and 2, 2016. Review of Resident CR1's MAR indicated [REDACTED]. An interview with the Nursing Home Administrator and the Director of Nursing on December 15, 2016, at 2:00 PM confirmed the above findings for Resident CR1. Clinical record review for Resident 8 revealed admission physician's orders [REDACTED]. if no bowel movement eight hours after the [MEDICATION NAME] suppository. Review of bowel elimination documentation for Resident 8 dated October 2, 2016 through October 31, 2016, revealed that the staff noted no bowel activity for Resident 8 on October 19, 20, 21, 22, 23, and 24, 2016. The next bowel movement the staff recorded for Resident 8 was on October 25, 2016, at 10:20 PM. Review of Resident 8's MAR indicated [REDACTED]. Interview with the Nursing Home Administrator and the Director of Nursing on December 16, 2016, at 10:30 AM confirmed the above findings for Resident 8. 483.25(e)(1)-(3) No Catheter, Prevent UTI, Restore Bladder Previously cited 1/15/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 1/15/16 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 1/15/16

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to prevent resident accidents with serious injuries for two of 14 residents reviewed (Residents 15 and 21). Findings include: The facility policy entitled Resident Fall Prevention last reviewed November 15, 2016, indicated that the facility would limit falls or prevent the occurrence of falls within parameters that can be controlled, through structured program interventions. It is the intent of the facility to minimize the severity of injuries sustained from falls. The residents identified at high risk for falls are residents who score a 10 or higher on the facility's fall risk assessment form. The facility will put in place interventions according to individual needs for those residents identified as high risk. The facility will investigate falls immediately and implement interventions if deemed necessary. Clinical record review for Resident 15 revealed a health status note dated August 30, 2016, at 9:58 PM. The note indicated that Resident 15 was on the floor between the bed and the wall. The resident slipped and lost her footing while ambulating from the bathroom with Employee 7 (Nurse Aide). Resident 15 complained of severe right hip pain. The nurse observed Resident 15's right foot was externally rotated. The physician ordered the facility to transport Resident 15 for an evaluation in the emergency room . The hospital admitted Resident 15 with a right hip fracture. The facility investigation into the fall revealed that Employee 7 was ambulating Resident 15 without the use of a gait belt. Resident 15's physician's orders [REDACTED]. Review of Resident 15's Closet Care Card (a worksheet that is located on the inside door of the resident's closet to provide information for staff detailing the care the resident needs) updated June 23, 2016, indicated that Resident 15 required one assist with a rolling walker and gait belt for ambulation. Clinical record review for Resident 15 revealed a fall risk evaluation dated June 6, 2016, with a fall risk score of 15. The evaluation indicates a score of 10 or above represents a high risk for falls. An interview with the Nursing Home Administrator and the Director of Nursing on December 15, 2016, at 11:30 AM confirmed that Employee 7 failed to utilize a gait belt when ambulating Resident 15. The facility failed to prevent a fall with actual harm. Review of Resident 21's annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) assessment dated [DATE], indicated that she scored a 12 on her BIMS (Brief Interview for Mental Status, used to determine cognition with 15 being the highest). Clinical record review for Resident 21 revealed nursing documentation dated May 19, 2016, at 8:48 PM indicating that the staff called the writer to Resident 21's room where the writer found Resident 21 on the floor. The documentation indicated that Resident 21 fell when traveling back to her room from the bathroom down the hallway. Review of the facility's investigation of Resident 21's fall on May 19, 2016, revealed that the facility identified that the possible root cause of the fall was related to illness, as Resident 21 began the use of an antibiotic on May 13, 2016, for pneumonia and had confusion. The writer of the incident report (signed by the Nursing Home Administrator, the Director of Nursing, and the facility's medical director) noted, N/A, (not applicable) for new interventions or actions taken with this incident. An interview with the Director of Nursing and the Nursing Home Administrator on December 15, 2016, at 12:00 PM confirmed that the facility had no evidence of implementing any new interventions to prevent fall recurrence for Resident 21 after the May 19, 2016, fall. Clinical record review of nursing documentation dated May 24, 2016 (five days later), at 4:18 AM revealed that staff summoned the writer to Resident 21's room at, 1:40 AM, where the writer found Resident 21 on the floor. The documentation indicated that Resident 21 stated that she slipped on her way to the bathroom. Nursing documentation dated May 24, 2016, at 4:00 AM revealed that at 3:30 AM Resident 21 complained of right hip pain and stated that she could not move it. (Resident 21) cried out in (pain) when right hip touched or moved. Staff contacted emergency services who transported Resident 21 to the hospital. The facility's investigation into the fall revealed that Resident 21's transfer status was independent with rolling walker. Review of the information submitted by the facility dated May 24, 2016, revealed that Resident 21's care plan indicated that she was independent with a rolling walker in her room and hallway. A hospital discharge summary for Resident 21's stay from May 24 to 31, 2016, noted that Resident 21 had a fall with a right subcapital (just below the head of the femur leg bone) hip fracture. Review of the facility's investigation of Resident 21's fall on May 24, 2016, revealed that the facility again identified that the possible root cause of the fall was related to confusion and the recent antibiotic use for pneumonia. The facility failed to implement new interventions following Resident 21's fall on May 19, 2016, in an effort to prevent fall recurrence, which occurred on May 24, 2016, resulting in major injury. The MDS (Minimum Data Set) 3.0 Section J defines a fall as an unintentional change in position coming to rest on the ground, floor, or next lower surface; and an intercepted fall where the resident catches him/herself or is intercepted my another person is still considered a fall. Nursing documentation dated June 11, 2016, at 2:16 PM noted that Resident 21 refused to stand during care and attempted to drop to her knees but was supported (intercepted) by two nurse aides. Nursing documentation dated June 15, 2016, at 7:04 PM noted new physician's orders [REDACTED]. Nursing documentation dated June 15, 2016, at 11:04 PM revealed that Resident 21's X-ray report indicated that the prosthetic right hip was dislocated. Nursing documentation dated June 16, 2016, at 2:29 PM indicated that Resident 21 went to the emergency room at 8:30 AM. emergency room documentation dated June 16, 2016, noted that Resident 21's history included that four to five days ago, while getting out of bed, Resident 21 flexed her leg and then had difficulty bearing weight and was holding her hip flexed. Since then, Resident 21 was not able to stand or bear weight. An interview with the Nursing Home Administrator and the Director of Nursing on December 14, 2016, at 2:00 PM confirmed that the facility had no investigation, or evidence of changes to her fall prevention plan of care, in response to this intercepted fall for Resident 21 on June 11, 2016. Review of Resident 21's fall prevention plan of care initiated March 19, 2015, instructed staff to ensure that Resident 21 wore shoes or nonskid slippers. Nursing documentation dated September 13, 2016, at 8:22 AM revealed that staff heard a female resident saying, .get off the floor. Staff responded to find Resident 21, barefoot, on the floor. Review of the facility's investigation of the September 13, 2016, fall revealed that the facility did not investigate the absence of proper footwear (staff failure or resident removal). The investigation included no new interventions directed at preventing fall recurrence for Resident 21 (the only intervention was to perform neurological checks for 72 hours). Nursing documentation dated September 15, 2016, at 6:11 PM revealed that the staff called the writer to Resident 21's room where the writer found her on the floor. The documentation indicated that Resident 21 had a hematoma (localized collection of blood presenting with bruising and swelling) over her left eye and the facility sent her to the emergency room . The facility failed to thoroughly investigate and implement new interventions following Resident 21's fall on September 13, 2016, in an effort to prevent fall recurrence, which occurred on September 15, 2016, resulting in an injury. 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices Previously cited 1/15/16 28 Pa. Code 211.10 (d) Resident care policies Previously cited 1/15/16 28 Pa. Code 211.11 (d) Resident care plan Previously cited 1/15/16 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services Previously cited 1/15/16

Based on observation, clinical record review, staff interview, and review of the social services job description, it was determined that the facility failed to implement social service interventions to prevent the decline for one of 12 sampled residents (Resident 9). Findings include: The job description entitled Medical Social Worker acknowledged by Employee 2, social worker, indicates that the social worker works in collaboration with physicians and other health care personnel in resident evaluation and treatment to further their understanding of significant social and emotional factors underlying resident's health problems. The social worker provides planned services to restore residents to optimum social and health adjustment within the resident's capacity. Interview with Employee 2, social services, on January 12, 2016, at 11:40 AM revealed that Resident 9 thinks the facility food is poisoned so she will not eat it, but accepts food her daughter brings in at night. Clinical record review for Resident 9 revealed that the facility admitted her on August 19, 2015, with dementia. Nursing notes dated August 20, 2015, indicated that Resident 9 was continent of bowel and bladder and transfers with the assistance of one person. Review of the weight log indicated that Resident 9's weight was 108.6 pounds on this date. Clinical record review for Resident 9 revealed social services notes dated August 20, 2015, that indicated that she was upset because of her placement and was attempting to elope from the facility. Nursing notes dated August 21, 2015, indicated that Resident 9 refused care, medications, and was not adjusting well to the facility. Resident 9 only needed one person assistance to transfer and complete ADL's (activities of daily living). Review of an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) dated August 26, 2015, indicated that the facility admitted Resident 9 with no cognitive impairment, requiring minimal assistance from staff to perform ADL's, and she was continent of both bowel and bladder. Review of the Care Area Assessment (CAA) dated August 26, 2015, indicated that it was a potential problem for Resident 9 that she has a history of depression with no current treatment. Resident 9 would rather be home and is feeling down due to being in the facility. There was no documented evidence in Resident 9's clinical record indicating that Employee 2 implemented any interventions to help her accept placement to the facility and acclimate to the environment despite the facility's knowledge, at this point, that she was not accepting care and placement. Social services notes dated August 30, 2015, revealed that Resident 9 refused medications, showers, exit seeks, feels depressed due to admission to facility, has a poor appetite, and is upset with her daughter for admitting her to the facility. There was no evidence in Resident 9's clinical record indicating that Employee 2 implemented any interventions to help her accept placement to the facility and acclimate to the environment. There was no evidence in Resident 9's clinical record that Employee 2 devised a plan for staff to follow with approaches that are specific to Resident 9's needs to help her accept care from staff. There was no evidence that staff were educating Resident 9 of the potential risks of refusing care such as bathing, eating, and refusing her medications. Nursing notes dated September 2, 2015, indicated that Resident 9 had lost 8.6 pounds since her admission two weeks ago. Nursing notes dated September 13, 2015, indicated that Resident 9 continued to have a poor appetite, refused her shower, and a body audit. There was no evidence that staff offered Resident 9 a shower at a better time for her or even a bed bath. There was no evidence that staff educated Resident 9 on the negative consequences of not bathing or refusing a body audit. There was no evidence in Resident 9's clinical record that Employee 2 devised a plan for staff to follow with approaches that are specific to Resident 9's needs to help her accept care from staff. Social services notes for October 2015, revealed the following dates that Employee 2 documented that Resident 9 was not accepting placement to the facility and never implemented interventions to help her accept placement and acclimate to the environment: October 5, 2015, Resident 9 spending a lot of time in bed and appears to have lost weight. October 7, 2015, Employee 2 confirmed that Resident 9 lost 10 pounds in one month refusing most meals. Nursing notes dated October 8, 2015, indicated that Resident 9 appeared thin and refuses the food on her tray because she thinks staff was poisoning her food. There was no evidence that indicated Employee 2 educated Resident 9 that staff is not poisoning her food and implemented interventions to help her accept the facility food. Social service notes indicated that on October 12, 2015, Employee 2 informed Resident 9's daughter that her refusal to eat or get out of bed has caused a decline in her health and suggested comfort care measures for her mother. Nursing notes dated October 10, 2015, indicated that Resident 9 was incontinent of urine and soaked her entire bed. Resident 9 refused to allow staff to change her clothes, as she would only accept care and food from her daughter. Nursing notes dated October 20, 2015, indicated that Resident 9 was refusing to allow staff to weigh her. There was no evidence in Resident 9's clinical record that Employee 2 educated Resident 9 of the risks of not allowing staff to obtain a weight. Review of the weight log indicated that on November 2, 2015, Resident 9's weight was 95 pounds, indicating that her refusal to consume the facility food was causing a weight loss. Social services notes for November 2015, revealed the following dates that Employee 2 documented that Resident 9 was not accepting placement to the facility and never implemented interventions to help her accept placement and acclimate to the environment: November 27, 2015, Resident 9 told Employee 2 she was leaving the facility and to get out of her room. Employee 2 documented that Resident 9 does not appear delirious, refuses ADL's, yells, and swears at staff. The last social service note in the clinical record dated November 30, 2015, revealed that Resident 9 yells, screams, and swears for staff to leave her room. Resident 9 isolates herself in her room, appears down, depressed, and sleeps often. Employee 2 was aware that Resident 9 had no current treatment for [REDACTED]. There was no evidence in Resident 9's clinical record that she was informing Resident 9's physician of the lack of antidepressant medication in her drug regimen. Physician's notes dated November 5, 2015, indicated that Resident 9's physician diagnosed her with failure to thrive. Nursing notes from November 2015, revealed the following dates that nursing staff documented that Resident 9 was not accepting placement and acclimating to the environment: November 8, 2015, Resident 9 refused to get out of bed and had a poor appetite. November 14, 2015, Resident 9 was incontinent of bowel, refusing to leave the bathroom, refusing to get dressed, and aggressive with nursing during incontinence care. November 21, and 22, 2015 Resident 9 refused to get out of bed, refused to shower, and had a poor appetite. November 25, 2015, Resident 9 refused to have laboratory values drawn, refused restorative ambulation, a shower, and care. Nursing notes from December 2015, revealed the following dates that nursing staff documented that Resident 9 was not accepting placement and acclimating to the environment: December 2, 2015, Resident 9 was incontinent of urine and had a poor appetite. December 7, 2015, Resident 9 refused to shower. Nursing notes dated January 8, 2016, indicated that Resident 9 fell out of bed to the floor. Resident 9 was nonverbal throughout the day, reaching into the air, and pulling her legs into the fetal position. Nursing notes dated January 10, 2016, indicated that Resident 9 refused to get out of bed and refused to allow staff to change her despite the entire bed being wet. Resident 9 grimaced in pain when staff repositioned her. Nursing notes dated January 13, 2016, indicated that Resident 9 was incontinent of bowel and bladder. Observation of Resident 9 throughout the survey from January 12 through January 15, 2016, indicated that she lays in bed all day. Interview with the Director of Nursing and the Administrator on January 13, 2016, at 2:30 PM confirmed that they had no evidence indicating that Employee 2 provided social service interventions to encourage Resident 9 to acclimate and accept placement to the long term care facility despite the numerous decline in her condition and health status. 28 Pa. Code 211.16 (a) Social services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate treatment and services to prevent the decline for one of 12 sampled residents (Resident 9). Findings include: Interview with Employee 2, social services, on January 12, 2016, at 11:40 AM revealed that Resident 9 thinks the facility food is poisoned so she will not eat it, but accepts food her daughter brings in at night. Clinical record review for Resident 9 revealed that the facility admitted her on August 19, 2015, with dementia. Nursing notes dated August 20, 2015, indicated that Resident 9 was continent of bowel and bladder and transfers with the assistance of one person. Review of the weight log indicated that Resident 9's weight was 108.6 pounds on this date. Current physician's orders [REDACTED]. Clinical record review for Resident 9 revealed social services notes dated August 20, 2015, that indicated that she was upset because of her placement and was attempting to elope from the facility. Nursing notes dated August 21, 2015, indicated that Resident 9 refused care, medications, and was not adjusting well to the facility. Resident 9 only needed one person assistance to transfer and complete ADL's (activities of daily living). Review of an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) dated August 26, 2015, indicated that the facility admitted Resident 9 with no cognitive impairment, requiring minimal assistance from staff to perform ADL's, and she was continent of both bowel and bladder. Review of the Care Area Assessment (CAA) dated August 26, 2015, indicated that it was a potential problem for Resident 9 that she has a history of depression with no current treatment. Resident 9 would rather be home and is feeling down due to being in the facility. There was no documented evidence in Resident 9's clinical record indicating that the facility provided appropriate resources to deal with her mental and psychosocial adjustment difficulty or provided treatment and services to acclimate her to the environment despite the facility's knowledge that she was not accepting care and placement. Social services notes dated August 30, 2015, revealed that Resident 9 refused medications, showers, exit seeks, feels depressed due to admission to facility, has a poor appetite, and is upset with her daughter for admitting her to the facility. There was no evidence in Resident 9's clinical record indicating that the facility provided appropriate treatment and services to deal with her mental and psychosocial adjustment difficulty and signs of depression. Nursing notes dated September 2, 2015, indicated that Resident 9 had lost 8.6 pounds since her admission two weeks ago. Nursing notes dated September 13, 2015, indicated that Resident 9 continued to have a poor appetite, refused her shower, and a body audit. Social services notes for October 2015, revealed the following dates that Employee 2 documented that Resident 9 was not accepting placement to the facility and never implemented appropriate treatment and services to help assist her in acclimating to the environment: October 5, 2015, Resident 9 spending a lot of time in bed and appears to have lost weight. October 7, 2015, Employee 2 confirmed that Resident 9 lost 10 pounds in one month refusing most meals. Nursing notes dated October 8, 2015, indicated that Resident 9 appeared thin and refuses the food on her tray because she thinks staff was poisoning her food. Nursing notes dated October 10, 2015, indicated that Resident 9 was incontinent of urine and soaked her entire bed. Resident 9 refused to allow staff to change her clothes, as she would only accept care and food from her daughter. Social services notes indicated that on October 12, 2015, Employee 2 informed Resident 9's daughter that her refusal to eat or get out of bed has caused a decline in her health and suggested comfort care measures for her mother. Nursing notes dated October 20, 2015, indicated that Resident 9 was refusing to allow staff to weigh her. Review of the weight log indicated that on November 2, 2015, Resident 9's weight was 95 pounds, indicating that her refusal to consume the facility food was causing a weight loss. Social services notes for November 2015, revealed the following dates that Employee 2 documented that Resident 9 was not accepting placement to the facility: November 27, 2015, Resident 9 told Employee 2 she was leaving the facility and to get out of her room. Employee 2 documented that Resident 9 does not appear delirious, refuses ADL's, yells, and swears at staff. The last social service note in the clinical record dated November 30, 2015, revealed that Resident 9 yells, screams, and swears for staff to leave her room. Resident 9 isolates herself in her room, appears down, depressed, and sleeps often. Employee 2 was aware that Resident 9 had no current treatment for [REDACTED]. There was no evidence in Resident 9's clinical record that she was informing Resident 9's physician of the lack of antidepressant medication in her drug regimen. Physician's notes dated November 5, 2015, indicated that Resident 9's physician diagnosed her with failure to thrive. Nursing notes from November 2015, revealed the following dates that nursing staff documented that Resident 9 was not accepting placement, acclimating to the environment, and showing signs of depression: November 8, 2015, Resident 9 refused to get out of bed and had a poor appetite. November 14, 2015, Resident 9 was incontinent of bowel, refusing to leave the bathroom, refusing to get dressed, and aggressive with nursing during incontinence care. November 21, and 22, 2015, Resident 9 refused to get out of bed, refused to shower, and had a poor appetite. November 25, 2015, Resident 9 refused to have laboratory values drawn, refused restorative ambulation, a shower, and care. Nursing notes from December 2015, revealed the following dates that nursing staff documented that Resident 9 was not accepting placement, acclimating to the environment, and showing signs of depression: December 2, 2015, Resident 9 was incontinent of urine and had a poor appetite. December 7, 2015, Resident 9 refused to shower. Nursing notes dated January 8, 2016, indicated that Resident 9 fell out of bed to the floor. Resident 9 was nonverbal throughout the day, reaching into the air, and pulling her legs into the fetal position. Nursing notes dated January 10, 2016, indicated that Resident 9 refused to get out of bed and refused to allow staff to change her despite the entire bed being wet. Resident 9 grimaced in pain when staff repositioned her. Nursing notes dated January 13, 2016, indicated that Resident 9 was incontinent of bowel and bladder. Observation of Resident 9 throughout the survey from January 12 through January 15, 2016, indicated that she lays in bed all day. Interview with the Director of Nursing and the Administrator on January 13, 2016, at 2:30 PM confirmed that they had no evidence indicating that the facility provided appropriate treatment and services to encourage Resident 9 to acclimate and accept placement to the long term care facility despite the numerous declines in her condition and health status. 28 Pa. Code 211.16 (a) Social services 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 3/27/15 and 7/13/15 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 3/27/15