Every finding on record at Ava Nursing and Rehab Center

Based on review of established infection control guidelines, policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of 44 residents reviewed (Resident 128) and failed to failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of 44 residents reviewed (Residents 54, 107, 130).Findings include: The facility's policy regarding wound care, dated January 18, 2026, revealed that staff were to remove gloves and perform hand hygiene after removing the dirty dressing and prior to placing the clean dressing. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 128, dated July 7, 2026, indicated that the resident was cognitively intact, required assistance for daily care needs, and had a surgical wound. Physician's orders for Resident 128, dated July 22, 2026, included an order to cleanse the buttocks with soap and water, apply medi-honey to open area and apply dry dressing over open area. Physician's order for Resident 128 dated July 28, 2026, included an order to cleanse the surgical wound with 0.125% Dakin's solution (solution used to cleanse wounds), pat dry, apply Dakin's moistened fluffed gauze, cover with dry gauze and then wrap with gauze wrap. Observations of wound care with Resident 128 on August 19, 2026, at 11:45 a.m. revealed that Licensed Practical Nurse 3 donned gloves, washed the buttocks and open wound with a washcloth, patted dry, opened gauze pads, opened bordered gauze pad, applied medi-honey to the gauze pad, applied the gauze pad with medi-honey to the wound, then covered the area with a bordered gauze and dated the dressing with a marker from her pocket. She pulled the resident's pants up and then removed her gloves and washed her hands. She donned a new pair of gloves, poured Dakin's solution into a cup, opened gauze pads and placed them into the cup of Dakin's solution, removed the resident's Draco boot (a special surgical boot), removed his sock, cut the gauze off, removed the gauze from the wound, took the Dakin's-soaked gauze out of the cup and cleansed the wound with it. She opened more gauze pads and placed them into the Dakin's solution and then applied them to the wound. She wrapped the foot with gauze, applied tape, removed a marker from her pocket and dated the dressing, returned the marker to her pocket, applied the resident's sock and gathered the dirty dressings and other supplies. She then removed her gloves and washed her hands. Interview with the Infection Control Nurse and Director of Nursing on August 19, 2026, at 1:48 p.m. revealed that Licensed Practical Nurse 3 should have worn a gown while changing Resident 128's wound dressings and should have changed gloves and performed hand hygiene when going from dirty to clean while dressing the wounds. CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated January 18, 2026, indicated that enhance Barrier precautions were used to prevent the spread of multi-drug resistant organisms to residents. EBP would apply when a resident was infected or colonized with a CDC-targeted MDRO, but did not have a wound or indwelling medical device (central lines, urinary catheters, feeding tubes, and tracheotomies), and did not have secretions or excretions that could not be covered or contained; a resident was not known to be infected or colonized with any MDRO, had a wound or indwelling medical device, and did not have secretions or excretions that were unable to be covered or contained; and contact precautions did not otherwise apply. Signs were to be posted on the door or wall outside of the resident's room communicate the type of precautions and PPE required. A quarterly MDS assessment for Resident 54, dated July 15, 2026, revealed that the resident was cognitively impairment, had a urinary catheter, and had diagnoses that included obstructive uropathy (blockage that makes it difficult to urinate). Physician's orders for Resident 54, dated July 13, 2026, included orders for the resident to have an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine). Observations of Resident 54 on August 17, 2026, at 10:04 a.m. and August 18, 2026, at 10:13 a.m. revealed that the resident was in bed and had a urinary catheter in place. A review of Resident 54's clinical record revealed that the was no physician's order or care plan developed for EBP. An admission MDS assessment dated [DATE], for Resident 107, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had medical diagnoses that included hemorrhage of rectum. Physician's orders for Resident 107, dated July 29, 2026, included orders to cleanse open area to coccyx (buttocks) with wound cleanser or normal saline, pat dry, pack wound with iodoform packing strip (cotton gauze with an antiseptic agent) and apply bordered dressing every day and night shift. Observation on August 17, 2026, at 10:00 a.m. revealed no evidence that the resident had enhanced barrier precautions in place. Interview with the Nursing Home Administrator on August 18, 2026, at 3:15 p.m. confirmed that Resident 107 did not have an order or sign on her door indicating that the resident is to be on enhanced barrier precautions. A nursing note for Resident 130, dated August 7, 2026, at 11:45 p.m. revealed the resident admitted to the facility and had an IV (intravenous) access device. Physician's orders, dated August 9, 2026, included orders for the resident to receive 900 milligrams (mg) of Daptomycin (antibiotic) intravenously one time a day for osteomyelitis (bone infection) for 37 administrations. A review of Resident 130's Medication Administration Record (MAR) for August 2026, revealed the resident received 900 mg of Daptomycin daily from August 10 through 20 ,2026. Observations of Resident 130 on August 18, 2026, at 3:33 p.m. revealed that the resident revealed that he had a PICC line to his right upper extremity. There was no signage or notification of the resident being on EBP posted at the resident's room. A review of the resident's clinical record revealed that there was no physician's order or care plan developed for EBP. Interview with Licensed Practical Nurse 4 on August 18, 2026, at 3:38 p.m. confirmed that there was no sign outside Resident 130's room to indicate that he was to have EBP in place. She indicated that he should have been on EBP precautions if he had a PICC line. Interview with the nursing Home Administrator on August 19, 2026, at 9:47 a.m. confirmed that Resident 54 and 130 should have had EBP in place. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the kitchen.Findings include: The facility policy regarding food storage, dated January 18, 2026, revealed that food was to be received and stored in a manner that complied with safe food handling practices. All foods in the refrigerator and freezer were to be covered, labeled, and dated. Observations in the kitchen's walk-in refrigerator and freezer on August 17, 2026, at 9:09 a.m. and 9:14 a.m. revealed that there was a bag of lettuce in the refrigerator that was open and not dated, an open box of frozen hamburgers in the freezer that were open to air, and a bag of beef jerky in the reach in refrigerator that was labeled mom. Observations in the kitchen on August 19, 2026, at 11:37 a.m. and 12:39 p.m. revealed that a door near the dietary Manager's office that led to the outside was propped open with a cardboard box and there were four loose and/or broken floor tile in the dishwasher room. Interview with the Dietary Manager on August 17, 2026, at 9:14 a.m. confirmed that all food items in the kitchen were to be sealed, labeled, and dated. Interview with the Dietary Manager on August 19, 2026, at 11:41 a.m. and 12:39 p.m. confirmed that the door to the outside should not have been propped open and that maintenance was responsible for the loose/broken tile. 28 Pa. Code 211.6(f) Dietary services.

Based on a review of policies, as well as resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food to residents that was palatable and at safe and appetizing temperatures. Findings include: The facility's policy for food temperatures, dated January 18, 2026, revealed that the point of service temperature to residents would be within the range of 120-140 degrees Fahrenheit (F) based on the resident's preference. During an interview with a group of residents on August 18, 2026, at 1:00 p.m. they revealed they did not like the taste of the food and that it was bland. Interview with Resident 7 on August 17, 2026, at 10:04 a.m. revealed that she felt the food could be better. Interview with Resident 27 on August 17, 2026, at 10:28 a.m. revealed that her only complaint with the facility was that the food was lousy and you were not always served what was requested. Interview with Resident 53 on August 17, 2026, at 10:21 a.m. revealed that the breakfast this morning was terrible and he could have bounced the hard boiled egg off the floor. The posted menu for August 19, 2026, indicated the lunch meal was grilled ham, whipped sweet potatoes, mixed vegetables, and applesauce. A test tray for the lunch meal on the Oak Hall on August 19, 2026, revealed that the cart left the kitchen at 12:08 p.m., arrived on the hall at 12:09 p.m., and the last resident was served at 12:20 p.m. The test tray was tasted at 12:20 p.m. and the ham was 117.3 degrees (F), not hot to taste, was not grilled, and the mixed vegetables were bland. Interview with the Dietary Manager on August 19, 2026, at that time confirmed that the ham was not served at the proper temperature. Interview with the Dietary Manager on August 19, 2026, at 12:57 p.m. confirmed that the ham was not grilled and the mixed vegetables were to have butter with salt and pepper.

Based on a review of clinical records as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 44 residents reviewed (Residents 107, 114).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) dated May 27, 2026, for Resident 107, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had medical diagnoses that included hemorrhage of rectum. A progress note for Resident 107 dated July 1, 2026, at 10:00 a.m. indicated that an open area measuring 2 centimeters (cm) x 2cm x 1.5cm was noted on her right inner buttock. Certified Registered Nurse Practitioner gave orders for the wound to be cleansed with wound cleaner, pack with iodoform and cover with bordered gauze twice daily and as needed for soilage or dislodgement. A physician progress noted dated July 11, 2026, at 10:16 a.m. for Resident 107 indicated that the resident had a cyst on her right inner gluteal and to continue current treatment and follow up with wound consultant. Physician's orders for Resident 107 dated July 21, 2026, included orders to cleanse open area on right inner gluteal with wound cleanser or normal saline, pat dry, apply medical grade honey then calcium alginate and apply bordered dressing every shift. Review of the Treatment Administration Record (TAR) for Resident 107 dated July 2026 revealed that the resident did not receive treatment to the right inner gluteal until July 21, 2026. Interview with the Director of Nursing on August 18, 2026, at 12:47 p.m. confirmed that Resident 107 did not receive treatment to right inner gluteal until July 21, 2026 and missed 20 days of treatment. A quarterly MDS assessment for Resident 114, dated May 29, 2026, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs and had diagnoses that included corneal ulcer (an open sore on the clear, dome-shaped surface covering the front of the eye). Physician's orders for Resident 114 dated July 10, 2026, included an order for the resident to receive 0.3% Ofloxacin Ophthalmic Solution (eye drop used to treat bacterial eye infections) 1 drop in right eye four times per day for 10 days (40 doses). Review of the Medication Administration Record (MAR) for Resident 114 dated July 2026 revealed that the resident only received Ofloxacin Ophthalmic Solution for five days, receiving a total of 24 doses instead of the ordered 40 doses. Interview with Director of Nursing on August 20, 2026, at 11:04 a.m. revealed that Resident 114 did not receive the complete course of Ofloxacin Ophthalmic Solution eye drops and that she should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding medication administration, dated January 18, 2026, revealed that medications were to be administered in a safe and timely manner, and as prescribed. Medications were to be administered in accordance with physician's orders, including any required time frame. Observations made during medication administration on December 18, 2026, revealed that two medication administration errors were made during 28 opportunities for error, resulting in a medication administration error rate of 7.14 percent. Physician's orders for Resident 46, dated March 28, 2026, included an order for the resident to receive 20 milliequivalents (mEq) of Potassium Chloride three times a day, the medication was not to be crushed and given with food. Observations of medication administration for Resident 46 on August 18, 2026, at 08:42 a.m. revealed that Licensed Practical Nurse 1 prepared the resident's medication, including Potassium Chloride, by crushing them and placing them in pudding, and then proceeded to administer the crushed medications to the resident. Interview with Licensed Practical Nurse 1 at that time confirmed that he crushed the Potassium Chloride. Physician's orders for Resident 10, dated August 10, 2026, included an order for the resident to receive 500 milligrams (mg) of Velphoro (used to control phosphorus levels) daily before meals. Observations of medication administration for Resident 10 on August 18, 2026, at 08:55 a.m. revealed that Licensed Practical Nurse 2 prepared the resident's medication, including Velphoro, and then proceeded to administer the medication to the resident. The resident had already eaten his breakfast. Interview with Licensed Practical Nurse 2 on August 18, 2026, at 10:18 a.m. confirmed that the resident had already eaten breakfast and the medication should have been administered before breakfast as ordered. \28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending September 18, 2025 and a complaint survey ending May 13, 2026, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending August 20, 2026, identified repeated deficiencies related to quality of care, parenteral/IV fluids, and label/store drugs and biologicals. The facility's plan of correction for a deficiency regarding quality of care, cited during the surveys ending September 18, 2025 and May 13, 2026, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to quality of care. The facility's plan of correction for a deficiency regarding parenteral/IV fluids, cited during the survey ending September 18, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in correcting deficient practices related to parenteral/IV fluids. The facility's plan of correction for a deficiency regarding label/store drugs and biologicals, cited during the survey ending September 18, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the QAPI committee was ineffective in correcting deficient practices related to label/store drugs and biologicals. Refer to F684, F694, F761. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 44 residents reviewed (Resident 10).Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 7, 2026, indicated that the resident was cognitively intact and that he had pain that was treated with pain medication. Physician's orders for Resident 10, dated August 1, 2026, included an order for the resident to receive 5-325 milligrams (mg) of Oxycodone and Acetaminophen (a combination opioid medication) every six hours as needed for pain. A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 10's Oxycodone-Acetaminophen revealed that one tablet was signed out on the controlled drug log on August 6 at 8:49 p.m.; August 15 at 8:54 p.m., and August 16 at 8:51 p.m. There was no documented evidence in the clinical record to indicate that the signed-out doses of Oxycodone-Acetaminophen were administered to Resident 10 on the above dates and times. Interview with the Director of Nursing on August 20, 2026 at 11:42 a.m. revealed that there was no documented evidence that the above referenced doses of Oxycodone-Acetaminophen were administered to Resident 10 on those dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of manufacturer's instructions, observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured for one of 44 residents reviewed (Resident 42), and failed to ensure that the medications were appropriately labeled and dated when opened.Findings include: Manufacturer's instructions for Tuberculin Purified Protein Derivative, undated, revealed that the vial of Tuberculin solution should be dated when opened and discarded 30 days after it is opened. Observations of the East Hall medication room on August 20, 2026 at 1:04 p.m. revealed that there was an opened and undated vial of Tuberculin solution in the refrigerator. Interview with Licensed Practical Nurse 2 on August 20, 2026 at 1:04 p.m. revealed that the vial of Tuberculin solution should have been dated when opened. Interview with the Director of Nursing on August 20, 2026 at 1:18 p.m. revealed that the vial of Tuberculin solution should have been dated when it was opened. Physician's orders for Resident 42, dated July 30, 2026 included an order for the resident to receive Fluoxetine (anti-depressant) 20 milligrams (mg) one time a day, an order dated August 13, 2026 for the resident to receive 25 mg Myrbetriq (urinary frequency medication) one time a day, an order dated June 26, 2026 for the resident to receive 10 mg Buspirone (anti-anxiety medication) two times per day, an order dated August 6, 2026 for the resident to receive 100 mg Doxycycline (an antibiotic) two times per day, an order dated July 29, 2026 for the resident to receive 49-51 mg Entresto (blood pressure medication) two times per day, and an order dated August 4, 2026 for the resident to receive 20 milliequivalents (meq) potassium chloride two times per day. Observations of Resident 42 on August 19, 2026 at 8:59 a.m. revealed that the resident was sitting up at the bedside and had a cup of pills sitting in front of her on her bedside table. Interview with Licensed Practical Nurse 3 on August 19, 2026 at 9:00 a.m. revealed that she left Resident 42's pills at her bedside because the resident does not like to take them until later in the day. She stated that the resident is very picky and that she just leaves the pills with her to be taken at a later time. Interview with the Nursing Home Administrator on August 19, 2026 at 9:46 a.m. revealed that Resident 42's medications should not be left at bedside. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that central venous catheters were flushed per facility policy for one of 44 residents reviewed (Resident 1).Findings include: The facility's policy regarding flushing peripheral and Midline catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated January 18, 2026, indicated that the catheter was to be flushed with 0.9% sodium chloride before and after it was used to administer medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 10, 2026, indicated that the resident was cognitively intact, was receiving an antibiotic, had IV (intravenous) access, and had a diagnosis of pneumonia. A nursing note, dated July 13, 2026, revealed that the resident had a PICC (Peripherally Inserted Central Catheter- a long, thin, flexible tube inserted into a peripheral vein, usually in the upper arm, and threaded to a large vein near the heart) line inserted. Physician's orders for Resident 1 dated July 14, 2026, included an order for the resident to receive 2.25 grams of Zosyn (an antibiotic) intravenously every eight hours for five days for pneumonia. Review of the Medication Administration Record (MAR) for Resident 1, dated July 2026, revealed that 2.25 grams of Zosyn was administered every eight hours (8:00 a.m., 4:00 p.m., 12:00 a.m.) from July 14 through 22, 2026, however there was no documented evidence that the residents PICC line was flushed before and after the administration of the antibiotic. Interview with the Director of Nursing on August 20, 2026, at 12:19 p.m. revealed that there was no documented evidence that Resident 1's central venous catheter was flushed before and after the administration of medication. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 44 residents reviewed (Resident 9).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated August 11, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and received dialysis (life-sustaining medical treatment that cleans your blood and removes extra fluid when your kidneys fail). Physician's orders for Resident 9, dated June 24, 2026, included an order for the resident to have dialysis Monday, Wednesday, and Friday at 5:30 a.m. Physician's orders for Resident 9, dated August 10, 2026, included an order for the resident to receive 5 milligrams of Proscar (medication to treat an enlarged prostate once a day for benign prostatic hyperplasia (BPH enlargement of prostate gland). A review of Resident 9's Medication Administration Record dated August 2026, revealed that 5 mg of Proscar was not administered on August 10, 12, 14, 17, and 19, 2026, due to a leave of absence to receive dialysis. There was no documented evidence in Resident 9's clinical record to indicate that the order for Proscar was clarified to be given upon return for dialysis. Interview with the Director of Nursing on August 20, 2026, at 2:43 p.m. confirmed that Resident's 9's medication order should have been clarified with the physician to adjust medication administration with the dialysis schedule. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 44 residents reviewed (Residents 54, 58, 88).Findings include: The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2025, revealed that Section N was to be coded for medications received in the last seven days. Section N0415F1 was to be coded if the resident received an antibiotic medication in the previous seven days, and Section N0415J1 was to be coded if the resident received a hypoglycemic medication in the previous seven days. Physician's orders for Resident 54, dated July 3, 2026, included an order for Bacitracin (topical antibiotic) be applied to the resident's scrotum twice a day until healed. Review of the Medication Administration Record (MAR) for Resident 54, dated July 2026, revealed that staff applied Bacitracin to the resident's scrotum twice a day from July 3 through 22, 2026. However, a quarterly MDS assessment for Resident 54, dated July 15, 2026, revealed that Section N0415F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period. The RAI User's Manual, dated October 2025, revealed that Section N0300 Injections record the number of days that injections of any type were received during the last seven days. N0350 Insulin injections record the number of days that insulin injections were received during the last seven days. A quarterly MDS assessment for Resident 58, dated July 10, 2026, indicated that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnosis that included type two diabetes mellitus. Section N0300 Injections indicated that the resident received seven injections during the seven-day look-back period. Section N0350 Insulin injections indicated that the resident received seven days of insulin injections during the seven-day look back period. Physician's orders for Resident 58, dated July 7, 2026, included an order for the resident to receive 50 units Lantus (a type of insulin) two times daily. Review of the Medication Administration Record (MAR) for Resident 58, dated July 2026, revealed that staff administered 50 units Lantus twice a day from July 7 through July 10, 2026. There was no evidence that the resident received seven days of insulin or any type of injections. Interview with Registered Nurse Assessment Coordinator on August 20, 2026, at 2:07 p.m. confirmed that Resident's 58 only received four days of insulin injections and that the MDS was coded inaccurately. Physician's orders for Resident 88, dated August 9, 2025, included an order for the resident to receive 2.5 milligrams (mg) of Tirzepatide (hypoglycemic) subcutaneously every Thursday. Review of the MAR for Resident 88, dated July 2026, revealed that staff administered 2.5 mg of Tirzepatide to the resident on Thursday July 2, 2026. However, a quarterly MDS assessment for Resident 88, dated July 6, 2026, revealed that Section N0415J1 was not coded, indicating that the resident did not receive a hypoglycemic medication during the seven-day look-back assessment period. Interview with Registered Nurse Assessment Coordinator on August 20, 2026, at 2:22 p.m. confirmed that Resident 54's and 88's MDS assessments were coded incorrectly. 28 Pa. Code 211.5(f) Medical records

Based on a review of facility policies and clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 44 residents reviewed (Resident 11).Findings include: The facility's policy regarding Trauma Informed Care, dated January 18, 2026, revealed that the facility to provide care that was culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated June 17, 2026, revealed that the resident was understood, could understand, required assistance from staff for daily care needs, and was taking antidepressant medication. A care plan for Resident 11 dated June 12, 2026, indicated that she had diagnoses of PTSD, major depressive disorder, and schizoaffective disorder and was ordered psychotropic medication; however, a PTSD trauma assessment dated [DATE], indicated that the resident did not have any past trauma. There was no documented evidence that the facility identified Resident 11's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. An interview with the Social Services Director on August 20, 2026, at 1:53 p.m., confirmed that Resident 11 was abused by her father and that yelling and loud voices were triggers for her. Resident 11 requires low calm voices, The Social Services Director indicated that Resident 11's trauma history was not identified until after the social history was completed and confirmed that the intervention for low calm voices was not in the PTSD care plan and should have been. 28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of seven residents reviewed (Resident 6).Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a residents abilities and needs) dated April 13, 2026, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included high blood pressure. Physician's orders for Resident 6, dated May 5, 2026, included an order for the resident to receive 3.125 milligrams (mg) of Carvedilol (a blood pressure medication), two times a day and to hold the medication if the resident's systolic (top number) blood pressure was less than 110 or the heart rate was less than 55. Resident 6's Medication Administration Record (MAR), dated May 2026, revealed that on May 5, 2026 at 8:00 a.m. the resident's blood pressure was 106/62 indicating that the Carvedilol should have been held, however, it was administered. On May 5, 2026 at 8:00 p.m. the resident's blood pressure was 108/62 indicating that the Carvedilol should have been held, however, it was administered. On May 8, 2026 at 8:00 p.m. the resident's blood pressure was 98/62 indicating that the Carvedilol should have been held, however, it was administered. On May 9, 2026 at 8:00 a.m. the resident's blood pressure was 98/56 indicating that the Carvedilol should have been held, however, it was administered. On May 9, 2026 at 8:00 p.m. the resident's blood pressure was 102/60 indicating that the Carvedilol should have been held, however, it was administered. On May 11, 2026 at 8:00 p.m. the resident's blood pressure was 98/60 indicating that the Carvedilol should have been held, however, it was administered. Interview with the Director of Nursing on May 14, 2026 at 3:10 p.m. revealed that the Carvedilol should have been held on the above referenced dates. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 4 of 68 residents reviewed (Residents 19, 49, 69, 120). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for quarterly MDS assessments, the assessment completion date was to be no later than the assessment reference date (ARD - the last day of an assessment's look-back period) plus 14 calendar days. A quarterly MDS assessment for Resident 19, dated February 14, 2025, revealed that the MDS was documented in section Z0500B as being completed on March 4, 2025, which was four days late. A quarterly MDS assessment for Resident 49, dated July 2, 2025, revealed that the MDS was documented in section Z0500B as being completed on July 17, 2025, which was one days late. A quarterly MDS assessment for Resident 69, dated April 22, 2025, revealed that the MDS was documented in section Z0500B as being completed on June 16, 2025, which was 41 days late. A quarterly MDS assessment for Resident 120, dated January 21, 2025, revealed that the MDS was documented in section Z0500B as being completed on March 25, 2025, which was 49 days late. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on September 18, 2025, at 2:58 p.m. confirmed that the above quarterly MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual MDS assessments were completed in the required timeframe for 11 of 68 residents reviewed (Residents 26, 31, 35, 36, 38, 44, 54, 79, 108, 110, 113). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days and that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and for annual MDS assessments, the assessment completion date was to be no later than the assessment reference date plus 14 calendar days. An admission MDS assessment for Resident 26, dated February 28, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on March 4, 2025, which was four days late. An annual MDS assessment for Resident 31, dated February 16, 2025, revealed that the MDS was documented in section Z0500B as being completed on March 3, 2025, which was one day late. An annual MDS assessment for Resident 35, dated March 5, 2025, revealed that the MDS was documented in section Z0500B as being completed on April 1, 2025, which was 13 days late. An admission MDS assessment for Resident 36, dated May 5, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 9, 2025, which was one day late. An admission MDS assessment for Resident 38, dated March 24, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on March 31, 2025, which was one day late. An admission MDS assessment for Resident 44, dated June 19, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 30, 2025, which was one day late. An annual MDS assessment for Resident 54, dated March 5, 2025, revealed that the MDS was documented in section Z0500B as being completed on March 27, 2025, which was 8 days late. An admission MDS assessment for Resident 79, dated March 25, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on April 1, 2025, which was one day late. An admission MDS assessment for Resident 108, dated March 24, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on March 31, 2025, which was one day late. An annual MDS assessment for Resident 110 revealed that the ARD was May 31, 2024, and the ARD of the next annual MDS was June 10, 2025 (10 days late). An admission MDS assessment for Resident 113, dated April 29, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 6, 2025, which was one day late. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on September 18, 2025, at 2:58 p.m. confirmed that the admission and annual MDS assessments listed above were not completed within the required timeframes. 28 Pa. Code 211.5(f) Clinical Records.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for two of 68 residents reviewed (Residents 6 and 130). Findings include: A facility policy for Comprehensive Person-Centered Care Plans dated January 18, 2025, indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being and reflects currently recognized standards of practice for problem areas and concerns. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6 dated August 29, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. Physician's orders for Resident 6 dated September 13, 2025, included an order for staff to insert and maintain a peripheral intravenous device (a way of giving a drug or other substance through a needle or tube inserted into a vein, typically located in the arm, hand, or foot). Review of Resident 130's clinical record revealed that he was admitted to the facility on [DATE], with a diagnosis of hemiparesis (weakness or paralysis on one side of the body) following a stroke and esophageal cancer. He was transferred to the hospital on September 7, 2025, and returned to the facility on September 10, 2025. Physician's orders for Resident 130 dated September 14, 2025, included an order for staff to insert and maintain a peripheral intravenous device for intravenous antibiotics. An interview with the Director of Nursing on September 18, 2025, at 12:26 p.m. confirmed that Resident 6 and Resident 130 did not have care plans in place to address the care and treatment needs related to their intravenous devices. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic drugs (drugs that affect a person's mental state, emotions, and behavior) for two of 68 residents reviewed (Residents 63 and 67). Findings include: A facility policy related to the use of psychotropic medications, dated January 18, 2025, indicated that nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and to allow for discontinuation of medications when possible. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated July 11, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic medications (a psychotropic medication used to treat mental health disorders) and antidepressant medications (psychotropic medications used to treat depression) and had a diagnosis of Alzheimer's dementia, depression, and anxiety. Physician's orders for Resident 63, dated May 30, 2025, and June 25, 2025, revealed that the resident was to receive 25 milligrams (mg) of Trazadone (a psychotropic medication) three times daily, as needed for anxiety. Physician's orders for Resident 63, dated August 18, 2025, revealed that the resident was to receive 25 mg of Trazadone daily, as needed for agitation. Physician's orders for Resident 63, dated September 8, 2025, revealed that the resident was to receive 50 mg of Trazadone daily, as needed for agitation. Review of Resident 63's Medication Administration Record (MAR) for June 2025, through September 2025, revealed that the resident received 25 mg of Trazadone on June 5 at 11:22 a.m., June 7 at 2:10 p.m., June 18 at 1:38 p.m., June 25 at 11:33 a.m., June 27 at 9:56 a.m., July 2 at 1:48 p.m. and 7:17 p.m., July 4 at 9:00 a.m. and 2:08 p.m., July 5 at 9:33 a.m., July 6 at 1:02 p.m., July 9 at 9:25 a.m., July 13 at 11:14 a.m., July 16 at 10:47 a.m., July 23 at 4:29 p.m., August 19 at 1:01 p.m., August 23 at 1:31 p.m. and 6:15 p.m., and September 4 at 9:49 a.m. Review of Resident 63's MAR for September 2025, revealed that the resident received 50 mg of Trazadone on September 16 at 12:07 p.m. Review of Resident 63's clinical record revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Trazadone on the above-mentioned dated and times. Interview with the Director of Nursing on September 18, 2025, at 11:27 a.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Trazadone to Resident 63 on the above-mentioned dates/times. An admission MDS assessment for Resident 67, dated August 4, 2025, revealed that the resident was cognitively impaired, required assistance from staff for care needs, and had diagnosis that included dementia. Physician's orders for Resident 67, dated July 30, 2025, included for the resident to receive 100 milligrams (mg) of quetiapine (a psychotropic medication) at bedtime daily. A nurse's note for Resident 67 dated September 9, 2025, at 4:15 p.m. revealed that the resident's legal guardian did not sign the consent for the use of the psychotropic medication Seroquel (the brand name drug for quetiapine) stating she wants to see if the dose can be reduced and she wants the Geriatric-Psychiatry Nurse Practitioner to start handling this medications and evaluate the resident. Review of the Medication Administration Record (MAR) for Resident 67 dated September 2025, revealed that 100 mg of quetiapine was administered daily at bedtime from September 9, 2025, through September 18. 2025. Interview with the Director of Nursing on September 18, 2025, at 12:38 p.m., revealed that a referral was to be sent to the Geriatric-Psychiatry Nurse Practitioner (an advanced practice registered nurse who specializes in the mental health care of older adults, diagnosing and treating psychiatric conditions like depression, anxiety, and dementia) before she could see resident and address the Seroquel orders. The Director of Nursing confirmed that a referral should have been sent to the Geriatric-Psychiatry Nurse Practitioner on September 9, 2025, however, as of September 18, 2025, there was no documentation that a referral was sent and therefore the requested dose reduction of Seroquel had not been addressed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for one of 68 residents reviewed (Resident 63).Findings include: A facility policy related to the use of psychotropic medications, dated January 18, 2025, indicated that when determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team (IDT) conducts an evaluation of the resident. The evaluation will clarify whether other causes for symptoms have been ruled out, signs and symptoms are clinically significant enough to warrant medication therapy, a particular medication is clinically indicated to manage the symptoms or condition, and the actual or intended benefit of the medication is understood by the resident/representative. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated July 11, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic medications (a psychotropic medication used to treat mental health disorders) and antidepressant medications (psychotropic medications used to treat depression) and had diagnoses that included Alzheimer's dementia, depression, and anxiety. Physician's orders for Resident 63, dated April 23, 2025, revealed that the resident was to receive 0.25 milligrams (mg) of Risperidone (an antipsychotic medication) daily at bedtime related to dementia with agitation. Physician's orders for Resident 63, dated June 18, 2025, revealed that the resident was to receive 0.25 mg of Risperidone twice daily related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Risperidone. Physician's orders for Resident 63, dated July 7, 2025, revealed that the resident was to receive 0.25 mg of Risperidone three times daily related to dementia with agitation. There was no documented evidence in the resident's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Risperidone. Physician's orders for Resident 63, dated August 28, 2025, revealed that the resident was to receive 0.25 mg of Risperidone two times daily for seven days, then give 0.25 mg of Risperidone daily for seven days related to dementia with agitation. Physician's orders for Resident 63, dated August 28, 2025, revealed that the resident was to receive 0.5 mg of Rexulti (an antipsychotic medication) daily for seven days, then give 1 mg of Rexulti daily for seven days related to Alzheimer's dementia and dementia with agitation. Physician's orders for Resident 63, dated September 8, 2025, revealed that the resident was to receive 2 mg of Rexulti daily starting on September 13, 2025, related to dementia with agitation. There was no documented evidence in Resident 63's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to decreasing the Risperidone and initiating Rexulti. Interview with the Director of Nursing on September 18, 2025, at 1:48 p.m. confirmed that there was no documented evidence in Resident 63's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Risperidone and prior to initiating Rexulti. 28 Pa. Code 201.29(a)(j) Resident Rights.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 68 residents reviewed (Resident 11 and Resident 32). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 11, dated August 25, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included dementia. Physician's orders for Resident 11 dated August 21, 2025, included an order for the resident to use an event recorder (portable device that you wear or carry to record your heart's electrical activity) for a seven-day monitor related to a history of having atrial fibrillation (an irregular and often very rapid heart rhythm) and dizziness. Physician's orders dated August 22, 2025, included an order for the resident to see a neurologist within five to seven days for an Electroencephalogram (EEG- test that records the brain's electrical activity to detect any abnormal patterns that may indicate a predisposition to seizures). As of September 18, 2025, there was no documented evidence that the event monitor or the neurology consult was scheduled or completed for Resident 11 per the physician's orders. An interview with the Director of Nursing on September 18, 2025, at 3:15 p.m. confirmed that there was no documented evidence that the event recorder or the EEG was scheduled or completed and should have been. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated August 15, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, had two venous ulcers (ulcers caused by problems with blood flow in the leg veins), surgical wounds, an infection of the foot, and received dressings to the feet and surgical wound care. Physician's orders for Resident 32, dated August 13, 2025, included orders to cleanse the resident's right lower leg surgical incision and left lower leg open area with soap and water, apply xeroform (dressing used to prevent and treat infections and promote wound healing) to left lower leg wound and cover both areas with dry dressing daily every evening shift. Review of the resident's Treatment Administration Record (TAR) for August and September 2025, revealed no documented evidence that the treatment to the resident's right lower leg surgical incision and left lower leg open area was completed as ordered on August 17,18, 20, 25, 30 and September 15. Physician's orders for Resident 32, dated August 13, 2025, included orders to cleanse the resident's right and left surgical incision sites on the abdomen with soap and water and cover with dry dressing daily every evening shift. Review of the resident's TAR for August and September 2025, revealed no documented evidence that the treatment to the resident's right and left surgical incision sites on the abdomen was completed as ordered on August 17,18, 20, 25, 28, 29, 30 and September 4. Physician's orders for Resident 32, dated August 14, 2025, included orders to cleanse the resident's right great toe and right bunion with wound cleanser (rinsing solutions used to remove foreign materials on a wound surface), pat dry, apply betadine (an solution used to treat and prevent infection) soaked, fluffed gauze to the wound beds, and cover with dry dressing every evening shift and as needed for soilage/dislodgement. Review of the resident's TAR for August 2025, revealed no documented evidence that the treatment to the resident's right great toe and right bunion was completed as ordered on August 17,18, 20, 25, and 30. Physician's orders for Resident 32, dated August 14, 2025, included orders to cleanse the resident's bilateral legs with wound cleanser, pat dry, apply skin prep (creates a barrier to protect skin from irritants like medical adhesives) to closed fluid filled blisters, xeroform to open blisters, and cover with abdominal dressing (used for a wound with large amounts of drainage or used as padding for pressure points and cushioning) and wrap with gauze every evening shift and as needed for soilage/dislodgement. Review of the resident's TAR for August 2025, revealed no documented evidence that the treatment to the resident's bilateral legs was completed as ordered on August 17,18, 20, 25, 28, 29 and 30. Interview with the Assistant Director of Nursing on September 18, 2025, at 11:29 a.m. confirmed that there was no documented evidence that Resident 32's treatments were completed as ordered on the above-mentioned dates. A wound consult note for Resident 32, dated September 12, 2025, included orders to start tubigrip (compression bandage designed to provide support and even pressure to an injured or swollen limb) size D to bilateral legs daily related to edema. Physician's orders for Resident 32, dated September 13, 2025, included orders to apply tubigrips to the bilateral lower legs in the morning and take off in the evening for edema. Physician's orders for the resident, dated September 18, 2025, included orders to apply tubigrips size D to the bilateral lower legs in the morning and take off in the evening for edema. Observations of Resident 32 on September 18, 2025, at 10:42 a.m. revealed that he had returned from therapy and did not have tubigribs on his bilateral legs as ordered and a small skin tear (traumatic wound caused by direct contact between the skin and another object) to his right shin was observed. Interview with Nurse Aide 1 on September 18, 2025, at 10:46 a.m. indicated that she was not sure if Resident 32 was supposed to have tubigrips on his bilateral legs. Interview with Licensed Practical Nurse 2 on September 18, 2025, at 10:53 a.m. confirmed that Resident 32 was to have tubigrips on his bilateral legs. She believed they may have been soiled and thrown away. Interview with the Assistant Director of Nursing on September 18, 2025, at 11:29 a.m. confirmed that Resident 32's tubigribs should have been on and they were not. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 3 of 68 residents reviewed (Residents 14, 77, 120). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). The MDS assessment validation report from iQIES (a federal government website for the Centers for Medicare and Medicaid), dated March 25, 2025, through August 25, 2025, revealed that the following MDS assessments were submitted late: Resident 14 had a quarterly MDS assessment with a completion date of May 14, 2025, however, was not submitted until May 29, 2025. Resident 77 had a quarterly MDS assessment with a completion date of May 14, 2025, however, was not submitted until May 29, 2025. Resident 120 had a quarterly MDS assessment with a completion date of March 25, 2025, however, was not submitted until June 26, 2025. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on September 18, 2025, at 2:58 p.m. confirmed that the above quarterly MDS assessments were not submitted in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of the facility's accounts payable ledger, as well as interviews with staff, it was determined that the facility failed to operate in compliance with state regulations and codes. The facility's failure created a situation which placed the residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. Information provided by the facility on February 28, 2024, revealed that they had not paid the employees of the facility their due wages for the payroll due February 23, 2024. The amount due to cover the payroll was $189,422.71. Documentation provided by the facility revealed that they received email notification from the payroll company on February 21, 2024, that a wire transfer was required to distribute the payroll for February 23, 2024. Interview with facility's union president revealed that there was a significant chance that many staff would walk off the job if not paid by Friday, March 1, 2024, which would leave the residents without proper staffing to care for all of their needs. The facility's accounts payable ledger, dated February 28, 2024, revealed outstanding balances for: [NAME] Highlands [NAME] lab for $29,325.03. The last payment was made February 28, 2024, for $3000.00. Clearfield [NAME] Primary Care Assoc, Dr. [NAME] for $24,500.00. The last payment was made February 28, 2024, for $3000.00. [NAME] Elevator Corporation for $3056.47. The last payment was made February 22, 2024, for $2868.06. Specialty RX for $45,466.78. The last payment was made on February 22, 2024, for $4000.00. System Technologies for $3,349.58. The last payment was made on August 4, 2023, for $51.06. Wellsky for $3,259.50. The last payment was made on October 2, 2023, $4756.17. On February 28, 2024, at 3:53 p.m. the Director of Nursing was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the failure to operate in compliance with state regulations and codes by not paying staff their wages or vendor invoices that were incurred in the operation of the facility. An immediate action plan was submitted and contained the following: In response to the Immediate Jeopardy imposed at Ridgeview Healthcare and Rehabilitation Center regarding vendor payments and payroll dated February 23, 2024. The following is the facility response to the identified concerns with remedy listed for immediate resolution. [NAME] Highlands [NAME] - $29,325.03 Immediate resolution is as follows: A payment was made in the amount of $3,000 on February 28, 2024. The facility Business Office Manager has been in contact with the accounting department of [NAME] Highlands [NAME] to provide accurate invoices reflecting amounts due under the Medicare fee schedule. Upon receipt, payment arrangements will be made accordingly. Clearfield [NAME] Primary Care Associates - $24,500 Immediate resolution is as follows: A payment was made on February 28, 2024, in the amount of $3,000. The Medical Director was contacted by the Nursing Home Administrator on February 28, 2024, regarding past due balances and agreeable to payments to be made monthly moving forward. [NAME] Elevator Corporation - $3,056.47 Immediate resolution is as follows: A payment was made on February 22, 2024, in the amount of $2,868.06. The vendor is current with outstanding invoices. SpecialtyRx - $45,466,78 Immediate resolution is as follows: A payment was made on February 22, 2024, in the amount of $4,000 and in compliance with agreed upon terms with the vendor to be paid $4,000 weekly. System Technologies - $3,349.58 Immediate resolution is as follows: The vendor was paid in full on January 22, 2024. The ledger has been updated. Proof of payment provided. WellSky - $3,259.50 Immediate resolution is as follows: A payment was made on February 28, 2024, in the amount of $1,629.75. Proof of payment provided. Remaining balance will be paid in March 2024. February 23, 2024, Employee Payroll Immediate resolution is as follows: The CEO notified the Nursing Home Administrator on February 28, 2024, that payroll is to be funded with same day deposits by close of business of Friday, March 1, 2024. The facility instituted an employee fund for any monetary needs until payroll processed. Funds were made available via cash, CashApp, Venmo, and PayPal. Adequate staffing requirements are in place under federal and Pennsylvania guidelines for resident care as evidenced in day sheets and employee punch records. The organization is working with Empeon, the payroll vendor, on splitting payrolls of the facilities improving cash flow week to week. Currently, all facilities are paid on the same pay schedule. Effectively, Ridgeview Healthcare and Rehabilitation Center will remain on the same pay schedule; however, four of the facilities will be moved to the opposite week for payroll processing and improved cash flow. Staffing Contingency The Director of Nursing, Assistant Director of Nursing, Infection Preventionist, and the Registered Nurse Assessment Coordinator are all registered nurses. The Human Resources Director and the Dietary Manager are certified nursing assistants. The Nursing Home Administrator will be returning on Friday and is a registered nurse. Additionally, the facility's Nursing Home Administrator and the Human Resources Director have already spoken with both National Healthcare located in [NAME], Pennsylvania and TLC Staffing in Punxsutawney, Pennsylvania, confirming availability. Interviews on March 4, 2024, with Nurse Aide 1 at 9:49 a.m.; Licensed Practical Nurse 2 at 9:49 a.m.; Licensed Practical Nurse 3 at 9:50 a.m.; Licensed Practical Nurse 12 at 9:50 a.m.; Licensed Practical Nurse 13 at 9:51 a.m.; Speech Therapist 4 at 9:52 a.m.; Housekeeping Staff 14 at 9:54 a.m.; Occupational Therapist 15 at 9:55 a.m.; Licensed Practical Nurse 5 (the union president), at 10:10 a.m.; Registered Nurse 7 at 10:15 a.m.; Nurse Aide 8 at 12:41 p.m.; Nurse Aide 10 at 12:53 p.m.; and Nurse Aide 11 at 1:00 p.m., all confirmed that payroll was received. The Immediate Jeopardy was lifted on March 4, 2024, at 3:36 p.m. when it was confirmed that staff received their wages. 28 Pa. Code 201.14(g) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of vendor invoices, as well as interviews with vendors and staff, it was determined that the facility failed to operate in compliance with state regulations and codes. The facility's failure created a situation which placed the residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. The facility's Accounts Payable Ledger, dated March 7, 2023, revealed that between February 18, 2022, through March 7, 2023, multiple vendors had submitted invoices for payment for services provided. However, as of March 7, 2023, multiple vendors have not received payment for the services provided. Below is only a partial sample of the vendors that are still owed payment for services provided. An invoice from the vendor that provides fuel for the facility's back up generator, dated February 28, 2023, revealed that the facility owed them $788.28 for fuel that was delivered on August 8, 2022. Interview with the vendor on March 8, 2023, at 3:30 p.m. confirmed that the facility still owed them $788.28 for when fuel was delivered on August 8, 2022, for the backup generator. She indicated that due to the non-payment, they would not deliver any fuel if the facility would call. Information provided by the facility revealed that the vendor for sewage was owed $12,466.83. Interview with the sewage vendor on March 9, 2023, at 8:50 a.m. confirmed that they have not received payment from the facility since November, 2022, and that the facility currently has an outstanding balance of $16,502.76, which includes the facility's bill for the month of February. She indicated that a termination notice will be posted on the facility's door on March 10, 2023, due to non-payment. She indicated that once the notice is posted, if full payment was not received in 10 days, then sewage services would be terminated. An invoice from the vendor that provides service to the facility's resident transport van, dated December 5, 2022, revealed that the vendor was owed $4001.22 for services provided on November 8, 2022. Interview with the vendor on March 9, 2023, at 10:00 a.m. confirmed that they have not received payment from the facility and that the the facility still owed them $4001.22 for the November 8, 2022, service. She indicated that due to the non-payment, they would no longer provide service on the facility's resident transport van. Information provided by the facility revealed that a staffing vendor for nursing services, dated January 31, 2023, revealed that the facility owed them $1,372.50 for staffing provided on September 23, 2022, and $396.00 for staffing provided on October 7, 2022. An interview with the nursing staffing vendor on March 9, 2023, at 9:35 a.m. confirmed that they have not received any payment from the facility for the nursing staffing that was provided on September 23, 2022, and October 7, 2022. They indicated that they would not provide any further nursing staff to the facility due to the non-payment. Information provided by the facility revealed that the facility's hairdresser vendor, dated February 23, 2023, revealed that she was was expecting full payment for the services she had provided by March 10, 2023, and if payment was not received, she was going to terminate her services. Interview with the hairdresser vendor on March 9, 2023, at 10:00 a.m. confirmed that she has not received payment from the facility and was owed approximately $3,357.00. She indicated that today was her last day due to the facility's non-payment. Interview with the Nursing Home Adminstrator on March 8, 2023, at 2:25 p.m. revealed that he has been contacted daily from various vendors used by the facility regarding non-payment for services that they have provided. He indicated that all of the bills that are received by the facility are forwarded to the facility's corporate office. On March 9, 2023, at 1:10 p.m. the Nursing Home Adminstrator was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the failure to operate in compliance with state regulations and codes by not paying in a timely manner bills incurred in the operation of a facility. An immediate action plan was submitted and contained the following: The sewage vendor would be paid $12,466.83 and the remaining balance due on March 31, 2023. The backup generator fuel vendor would be paid in full on March 9, 2023. The facility's transport van service vendor would be paid in full on March 9, 2023. The facility's hairdresser vendor would be issued and mailed a check on March 16, 2023. The nursing staff vendor would be paid in full March 9, 2023. Adequate staffing would be provided under Federal and Pennsylvania guidelines. The Nursing Home Administrator will contact each vendor with outstanding balances to establish payment plans in conjunction with the Chief Financial Officer and Controller. All invoices received by the facility will reviewed/approved by the facility's Nursing Home Administrator and then submitted to the company's accounts payable department. On a weekly basis the controller will provide the facility's Nursing Home Adminstrator a statement of invoices paid for the prior week and a monthly statement of accounts payable for all vendors. The Immediate Jeopardy was lifted on March 10, 2023, at 3:10 p.m. when it was confirmed that payments were being made and received by some of the vendors with outstanding balances. 28 Pa. Code 201.14(g) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that one of nine residents reviewed received sufficient hydration (Resident CR2). Findings include: A dehydration (a deficit of total body water, with an accompanying disruption of metabolic processes) risk screening tool for Resident CR2, dated August 15, 2016, revealed that the resident was at moderate risk for dehydration. An initial Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR2, dated August 21, 2016, indicated that the resident was confused and had [DIAGNOSES REDACTED]. Resident CR2's care plan, initiated on August 19, 2016, indicated that the resident was at risk for dehydration; however, there was no information or interventions on the care plan regarding what the resident's daily fluid requirement was, and there were no individualized interventions on the plan for staff to follow if the resident did not meet his daily fluid requirement. A nutrition assessment for Resident CR2, dated August 27, 2016, indicated that the resident's daily fluid needs were 1,725 to 2,070 milliliters (ml's) per day. Resident CR2's fluid intake and output report for August 15 through September 15, 2016, indicated that the resident's fluid intake varied from 360 ml's on September 15, 2016, to 1,620 ml's on August 29, 2016, and there were no days in which the resident met his calculated required fluid needs. Review of a dietary supplement report for September 2016, revealed that the resident was offered 120 ml's of a dietary supplement every evening, and his intake varied between 0 and 100 percent. Review of records from the facility's hydration cart (a cart taken room to room for the purpose of increasing fluid intake) for August 25 through September 15, 2016, indicated that staff documented that the resident was sleeping when the hydration cart stopped at his room on August 23 and August 24, 2016, and there was no indication that fluids were offered. Documentation for August 25, 28 and 29, 2016, and September 1, 3, 5, 7, 11, 12, 13, 14 and 15, 2016, revealed that fluids were offered from the hydration cart; however, there was no documentation if the resident accepted the fluids or how much he drank. There was no documented evidence that the resident was offered fluids from the hydration cart on August 26, 27, 30 and 31, 2016, and September 2, 4, 5, 6, 8, 9 and 10, 2016. A nursing note, dated September 16, 2016, indicated that the resident had abnormal laboratory results and was transferred to the hospital on that date. Hospital discharge instructions, dated September 23, 2016, indicated that the reason for the resident's admission to the hospital was dehydration. Interview with the Nursing Home Administrator on November 14, 2016, at 3:05 p.m. confirmed that the hydration cart was to be taken room to room in the facility to provide extra fluids to the residents between meals. She indicated that she provided all available documentation related to fluids being provided to Resident CR2. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/28/16, 11/3/15, 8/14/15, 12/11/14.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned for one of 26 residents reviewed (Resident R3) who fell and suffered fractures, and failed to ensure that the residents' environment remained free of accident hazards caused by a resident with aggressive behaviors (Resident CR23) resulting in an accident in which one of 26 residents reviewed suffered a fracture (Resident R4). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated February 19, 2015, revealed that the resident was confused, required limited assistance with walking, and had a history of [REDACTED]. An incident report, dated April 12, 2015 at 2:35 a.m., revealed that Resident R3 was found in another resident's room in a sitting position on the floor with her right leg rotated outward, and she was transferred to the hospital and diagnosed with [REDACTED]. plan and staff interviews in order to determine if the hipsters were on at the time of the fall. The resident's daily nurse aide documentation for April 2015, revealed no documented evidence that the hipsters were on at the time of the fall. An incident report, dated May 26, 2015, revealed that Resident R3 was being fed her evening meal when she quickly stood up, lost her balance and fell on her left side. A nursing note, dated May 27, 2015 at 2:29 p.m., revealed that the resident complained of pain in the left hip and had facial grimacing during transfers, and a physician's orders [REDACTED]. The X-ray report, dated May 27, 2015, revealed that the resident had a fractured left hip. The facility's investigation report, dated May 26, 2015, revealed that the resident had gripper socks on at the time of the fall, but the report did not include evidence of a review of the resident's care plan and staff interviews in order to determine if the hipsters were on at the time of the fall. The resident's daily nurse aide documentation for May 2015 revealed no documented evidence that the hipsters were on at the time of the fall. Interview with Nurse Aide 12 on January 28, 2016 at 2:50 p.m., revealed that she could not recall if Resident R3 was using hipsters at the time of the falls. She indicated that it was her first day of working at the facility May 26, 2015, and she was not familiar with the resident. Interviews with the Nursing Home Administrator and Director of Nursing on January 28, 2016 at 10:15 a.m., confirmed that the investigations into Resident R3's falls did not include a review of the care plan and staff interviews related to the use of the hipsters. They could provide no evidence that the hipsters were on as care planned at the times of the resident's falls. The facility's policy for behavior assessment and monitoring, dated January 10, 2015, revealed that the staff were to assess the resident for the possible causes of the behavioral symptoms, develop individualized interventions to treat the cause in order to reduce the behavior occurrence, monitor the effectiveness of interventions and adjust the interventions based on the impact of behavior and other symptoms as warranted. An annual comprehensive MDS assessment for Resident CR23, dated August 14, 2015, revealed that the resident was admitted to the facilty on August 8, 2014, with [DIAGNOSES REDACTED]. Nursing notes for August 2014, revealed that the resident had verbal and physically violent behavioral outbursts that were directed at the staff and other residents that began shortly after his admission to the facility. A behavior care plan, dated August 27, 2014, revealed that the resident had the potential for self-harm related to impaired cognition and risk for elopement. The staff were to approach the resident in a calm manner, encourage him to verbalize his feelings, remove the resident from the source of stimulation that increased behavioral occurrences, encourage his participation in diversional activities such as playing cards, watching hunting videos, and looking at hunting magazines, along with monitoring the resident for changes in his behaviors and reporting those findings to the physician if noted. Nursing notes for Resident CR23, dated January 2, 2015 and February 20, 2015, revealed that the resident was verbally nasty to other residents and threatened other residents, and he also raised his hand and threatened to hit an unidentified female resident who was blocking his doorway. On February 13, 2015, the resident's care plan was updated to include a goal that the resident would not harm himself or other residents. On March 13, 2015, a social service note revealed that Resident CR23 became agitated when housekeeping cleaned his room, and that he continually paced the halls and became intimate with another resident. A nursing note, dated April 22, 2015, revealed that another resident wandered into Resident CR23's room and Resident CR23 was heard yelling and threatening the other resident. Resident CR23's care plan was revised on May 8, 2015, to include the placement of a, STOP sign on Resident CR23's door. Nursing and social service notes, dated May 10, 2015, revealed that the staff heard Resident CR23 yell, Get the f*** out of my room! Staff then heard a thump and entered Resident CR23's room to find Resident CR23 with his arm out stretched and another resident falling to the floor sliding against the dresser. When questioned by staff if he touched the other resident, Resident CR23 stated, If I would have touched her I would have broke her f***ing neck. The note indicated that the staff reminded Resident CR23 to be patient with the other residents and they would continue to monitor. On May 11, 2015, a social service note revealed that Resident CR23 indicated that he would kick out the window and leave, and that he also yelled at his roommate, Stop standing around doing nothing, so the staff removed the roommate to a common area and indicated that they would continue to monitor. A social services note, dated May 18, 2015, indicated that Resident CR23 was increasingly agitated and aggressive toward other residents. Care plan conference notes, dated June 4, 2015, indicated that Resident CR23 recently had more aggressive behaviors, that his medications were adjusted, and that the recreation staff were to see the resident on a one-to-one basis with the hope to enhance other meaningful experiences for him related to his increased behaviors. A nursing note, dated June 8, 2015, revealed that Resident CR23 became aggressive with his roommate when he stepped in front of his television and stated, Get him out of here before I punch him in the face. Staff removed the roommate to a common area and indicated that they would continue to monitor and redirect the resident when he was agitated. A behavior note, dated June 15, 2015, revealed that Resident CR23 became upset when his roommate began talking to himself and told him, If you don't shut up I will punch you! It was noted that Resident CR23 was becoming increasingly agitated at others who entered his room. A behavior note, dated June 15, 2015, revealed that a female resident accidently entered Resident CR23's room with her wheelchair, and Resident CR23 threatened to hit her if she did not get out. A note, dated June 16, 2015, revealed that Resident CR23 became physically and verbally abusive towards his roommate yelling at him, Get out of here you stupid f***er. I'm going to bash your head in! As a nurse entered Resident CR23's room, he threw a tray table at the other resident. Interventions provided by staff at that time included informing the resident that his roommate was permitted in the room and that his behavior was unacceptable. A social service note later that day indicated that staff would attempt to eliminate stimuli that angered the resident from the environment, would redirect the resident if such behavior occurred, and that staff were to relocate the roommate the next day to avoid the possibility of harm. A behavior note, dated June 26, 2015, revealed that another resident ducked under the STOP sign draped across the threshold of Resident CR23's door and entered his room. Resident CR23 became very angry, yelling and swearing at the other resident and threatened to push him to the floor before the staff intervened. A social service note, dated June 29, 2015, indicated that the staff were to monitor to prevent anger causing stimuli such as other residents wandering into Resident CR23's room. On June 30, 2015, a nursing noted indicated that Resident CR23 was lying in bed watching television when another resident attempted to enter his room. Resident CR23 stood in the doorway and yelled that he was going to kill the other resident, that this was his room and no one was allowed in. A nursing note, dated July 1, 2015, revealed that the same resident identified had wandered into Resident CR23's room, and a nurse aide heard Resident CR23 shouting, Get the f*** out of here! When the nurse aide reached the room, Resident CR23 was shoving the other resident into a closet. A nursing note, dated July 4, 2015, revealed that the same resident wandered into Resident CR23's room and staff heard him scream, Get the f*** out of here! I'll beat you to a f***ing pulp! Staff redirected the wandering resident out of Resident CR23's room and told Resident CR23 that his behavior was unacceptable to which he replied, Then keep the stupid f***er out of my room! A behavior note, dated July 8, 2015, revealed that Resident CR23 charged toward another resident who was standing outside his doorway, and swatted at him with the mesh stop sign that had been attached across the threshold of the door. This note documented that the resident was very territorial of his room and became upset whenever someone tried to go in. A social service note, dated July 9, 2015, indicated that the staff were to attempt to divert stimuli from the resident's environment and continue to monitor. Documentation indicated that the staff checked on Resident CR23 every 15 minutes for 24 hours from July 9 through 10, 2015; however, there was no evidence that new interventions were added to the resident's behavior care plan, and the intervention of checking the resident every 15 minutes was not continued beyond 24 hours. On July 16, 2015, a nursing note indicated that another resident entered Resident CR23's room, and Resident CR23 pushed the resident, who was caught by a nurse aide who happened to be passing by the room as the incident occurred. Admission information, dated July 29, 2015, revealed that Resident R4 was admitted to the facility that day with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A nursing note, dated August 1, 2015, revealed that the resident continuously wandered. A nursing note, dated August 6, 2015, revealed that Resident R4 wandered into other residents' rooms and became aggressive and stated, Why don't you cut my head off? several times when the staff tried to redirect him. A nursing note, dated August 6, 2015, revealed that Resident R4 was struck in the cheek by Resident CR23 when he wandered into Resident CR23's room. On August 7, 2015, an Interdisciplinary Team meeting note indicated that the incident between Resident R4 and Resident CR23 was discussed and that a new intervention to redirect Resident R4 from Resident CR23's room was added. On August 13, 2015, documentation from a care planning meeting indicated that the recreation staff would encourage Resident R4's participation in small group activities to help diminish his wandering. However, there was no evidence that a plan to prevent Resident R4 from wandering into other residents' rooms was developed. Additionally, despite evidence that Resident CR23's behavior care plan was not effective to prevent his behaviors toward other residents, evidence that the STOP sign was not effective in keeping other residents out of Resident CR23's room, and evidence that Resident CR23 was very territorial about his room, there was no documented evidence of any additions or modifications to Resident CR23's behavior prevention interventions. A nursing note dated August 16, 2015, and review of information submitted by the facility dated August 17, 2015, revealed that on August 16, 2015, Resident R4 was walking about the unit, approached the doorway, and was looking into Resident CR23's room when Resident CR23 pushed Resident R4, causing him to fall. When a Licensed Practical Nurse approached, Resident CR23 stated, I didn't punch him, I shoved him, but the next f***ing time I will. The Licensed Practical Nurse informed Resident CR23 that pushing, punching and hitting of any nature was inappropriate and not allowed. Resident CR23 replied, I pay taxes on this f***ing place and it's mine. I'll do what I want. An X-ray report for Resident R4, dated August 16, 2015, revealed that the resident suffered a fractured right hip and was sent to the hospital. Interview with Licensed Practical Nurse 17 on January 28, 2016 at 11:30 a.m., confirmed that the stop signs used across doorways did not always prevent Resident R4 from entering residents' rooms. She indicated that there was nothing in place to prevent the resident from entering other rooms, and when he entered other residents' rooms, the staff did not always document it. She also confirmed that Resident CR23 displayed aggressive behaviors toward elderly residents, that it was a constant, daily struggle to manage his outbursts, and his behavior escalated any time elderly residents came near him. Interview with Social Services Employees 18 and 19 on January 28, 2016 at 9:00 a.m., revealed that in an attempt to prevent residents from wandering into Resident CR23's room, the resident was moved into a private room located behind the nursing station on August 5, 2015. They indicated that the activities department was to increase the amount of one-on-one visits with Resident CR23 in order to decrease his aggressive behaviors toward other residents. However, activities attendance records for Resident CR23 revealed that the number of one-to-one activities provided decreased from 16 in July 2015, to 6 in August 2015, prior to the altercation on August 16, 2015. Interview with the Activities Director on January 28, 2016 at 10:00 a.m., revealed that she continued to hold small group activities in the common area that was between Resident CR23's private room and the nursing desk area. She indicated that the nurses' desk in front of Resident CR23's room was moved backward a couple feet in attempt to decrease traffic around the resident's room; however, wandering residents were still able to access the area. Interviews with the Director of Nursing and the Nursing Home Administrator on January 28, 2016 at 2:30 p.m., confirmed that the barriers across residents' room doors did not always work to keep Resident R4 out of other resident's room, and the resident's care plan did not include any other interventions to keep him from entering other residents' rooms. The Director of Nursing and the Nursing Home Administrator indicated that staff redirected Resident R4 when they found him in another resident's room, but there was no plan in place to prevent him from wandering into other residents' rooms. 42 CFR 483.25 (h) Free of Accident Hazards/Supervision/Devices. Previously cited 8/14/15. 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 8/14/15, 12/11/14. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 11/3/15, 8/14/15, 12/11/14.