Every finding on record at Avalon Care Center

Based on review of facility policy and clinical records, observations, and staff and resident interviews, it was determined that the facility failed to administer supplemental oxygen as ordered for one resident and promote cleanliness and prevent the spread of infection regarding respiratory care equipment for three of 25 residents reviewed (Residents R32, R53, and R72).Findings include:Review of facility policy entitled Oxygen Administration, dated 4/16/26, revealed Set the flow rate as ordered by physician; Oxygen shall be humidified as indicated by physician; Humidifier bottle shall be connected to the oxygen concentrator prior to setting flow rate.Review of facility policy entitled Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure [CPAP (therapy that keeps your airways open during sleep to treat sleep apnea and other breathing disorders) BiPAP (noninvasive device that helps people breathe by providing two levels of air pressure: higher when inhaling and lower when exhaling)] Support dated 4/16/26, revealed: Mask, nasal pillows, and tubing; clean daily by placing in warm, soapy water and soaking/agitating for five minutes, rinse with warm water and allow it to air dray between uses. Headgear; was with warm water and mild detergent as needed and allow to air dry. Resident R53's clinical record revealed an admission date of 9/20/24, with diagnoses that included sleep apnea, irregular heartbeat, muscle wasting, and lack of coordination. The clinical record revealed a physician's order dated 11/20/24, revealed to clean Resident R53's CPAP corrugated tubing and mask weekly by placing in warm soapy water, rinse with water and allow to air-dry on a towel. Clean mask by wiping, using a damp cloth with warm soapy water on it, rinse and allow the mask to air dry every Sunday on the night shift; and a physician's order dated 6/21/25, to change the distilled water daily.Resident R53's clinical record lacked physician's orders related to the care of his/her nebulizer equipment.Observation on 6/09/26, at 12:40 p.m. revealed Resident R53's CPAP mask contained dried substance inside the mask and was found inside of an opaque white shopping bag lying on the floor. The interior of the bag was noted to contain numerous moist black flecks of unknown substance scattered through the interior of the bag and on the CPAP mask. The humidifier chamber of the CPAP machine was observed to be discolored with a yellowish hue and was approximately 1/4 full of water. Resident R53's nebulizer mask was lying on his/her bed with the elastic strap wrapped around nebulizer motor. During an interview at that time Resident R53 shared that he/she has been in the facility for two years, has never received a new mask, staff don't clean his/her CPAP mask, and that he/she keeps it in that bag so it doesn't get broken because he/she can't afford a new one. Resident R53 also confirmed that he/she fills the humidifier chamber of the CPAP machine himself/herself, and staff do not clean it. Resident R32's clinical record revealed an original admission date of 6/05/23, with diagnoses that included respiratory failure, asthma, irregular heartbeat, and pleural effusion (fluid builds up between the thin membranes that line the lungs and the inside of the chest cavity).Resident R32's clinical record revealed the following physician's orders:Change the oxygen bag weekly and label with the date, dated 7/13/25Change the oxygen tubing weekly and label with the date dated 6/21/25.Change the nebulizer tubing and place clean tubing in a plastic bag, label and date the tubing and the bag, wipe down the nebulizer machine once a week, dated 6/24/25.Clean filter in oxygen concentrator weekly and replace every Sunday on night shift, dated 6/21/25.Clean the CPAP corrugated tubing and mask weekly by placing in warm soapy water, rinse with water and allow to air-dry on a towel. Clean mask by wiping, using a damp cloth with warm soapy water on it, rinse and allow the mask to air dry every Sunday on the night shift,Change the distilled water daily, 4/12/26Observation on 6/09/26, 1:50 pm revealed Resident R32's oxygen tubing to CPAP dated 5/17/26, the corrugated CPAP tubing was dated 4/06/26, and laying on top of the tray table and connected to the CPAP mask, his/her nebulizer mask lying on top of tray table and not in a bag. There was no filter in oxygen concentrator, and the air inlet was covered in a thick layer of gray fluffy substance, that blocked the pathway of air intake. During an interview at that time, Licensed Practical Nurse Employee E1 confirmed the above stated conditions and locations of Resident R32's CPAP and nebulizer equipment, that the oxygen concentrator lacked a filter, and the air inlet was covered in a thick layer of gray fluffy substance, that blocked the pathway of air intake. Resident R72's clinical record revealed an admission date of 6/23/25, with diagnosis that included Chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and hyperlipidemia (high cholesterol). Resident R72's clinical record revealed a physician's order dated 7/2/25, for oxygen at 2-3 liters per minute (lpm) to maintain O2 sat (oxygen level) greater than 90% via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) or mask; a physician's order dated 6/29/25, to clean filter in oxygen concentrator weekly and replace; a physician's order dated 6/29/25, to replace oxygen humidification bottle weekly and date.Observation on 6/9/26, at 2:35 p.m. revealed Resident R72 sitting on his/her bed with supplemental oxygen in place via nasal cannula and the oxygen concentrator liter flow set at 4 lpm. Further observation of the concentrator filter on the right side of the oxygen concentrator revealed a large amount of a gray fluffy substance covering the filter and the concentrator was running without a humidification bottle attached. During an interview on 6/09/26, at 2:00 p.m. the Director of Nursing (DON) confirmed the above stated conditions and locations of Resident R53's CPAP and nebulizer equipment, and that the nebulizer mask should be kept in a bag, and that the CPAP mask needed replaced. During an interview on 6/09/26, at 2:00 p.m. the DON confirmed the above stated conditions and locations of Resident R32's CPAP and nebulizer equipment, that the nebulizer mask should be kept in a bag, and that the oxygen concentrator needed replaced. During an interview on 6/9/26, at 2:35 p.m. DON confirmed that Resident R72's oxygen concentrator was on and set at 4 lpm and was not in accordance with the physician's order dated 7/2/25, for oxygen at 2-3 lpm. The DON further confirmed that Resident R72's oxygen concentrator's filter was dirty and should be cleaned and there was no humidification bottle on the concentrator.During an interview on 6/11/26, at 10:24 a.m. DON confirmed the facility didn't have a policy for cleaning and/or storage of oxygen and nebulizer equipment and followed the physician's orders for maintenance of the equipment. 28 Pa. Code 211.5(f)(viii) Medical records28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for four of 21 residents reviewed for showers/bathing (residents R2, R43, R53, and R77), and eight of 21 residents reviewed for call bell response times (Residents R21, R23, R29, R32, R42, R44, R65, and R66) Findings include:A Facility policy entitled Activities of Daily Living (ADL), Supporting dated 4/16/26, indicated that: residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Resident R53's clinical record revealed an admission date of 9/20/24, with diagnoses including sleep apnea, irregular heartbeat, muscle wasting, and lack of coordination Resident R53's was scheduled to receive his/her shower/bath on Monday and Thursday evenings. Further review of Resident R53's clinical record revealed that he/she received two of nine scheduled showers/baths in the last 30 days.During an interview on 6/09/26, at 12:40 p.m. Resident R53 shared that he/she does not receive showers/baths routinely, and that staff will state they are going to come get him/her for a shower but never do. Resident R2's clinical record revealed an initial admission date of 8/29/24, with diagnoses including Parkinson's Disease (disorder of the nervous system that causes nerve cells in parts of the brain to weaken, become damaged, and die, and can lead to difficulty walking, talking, or completing everyday tasks), high blood pressure, muscle wasting, and lack of coordination Resident R2 was scheduled to receive his/her shower/bath Tuesday and Friday afternoons. Further review of Resident R2's clinical record revealed that he/she received two of nine scheduled showers/baths in the last 30 days. During an interview on 6/09/26, at 12:47 p.m. Resident R2 shared that he/she does not receive showers/baths routinely, and that staff will state they are going to come get him/her for a shower but never do. Resident R43's clinical record revealed an admission date of 5/16/26, with diagnoses including respiratory failure, embolism (obstruction or blockage in a blood vessel] and thrombosis (blood clots block your blood vessels) of the lower extremity, heart failure, and Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood) Resident R43 was scheduled to receive his/her shower/bath on Wednesday and Saturday on the day shift. Further review of Resident R43's clinical record revealed that he/she received one shower/bath and one bed bath since admission. During an interview on 6/10/26, at 11:00 a.m. Resident R43 confirmed that he/she has only had one shower/bath since coming here and was washed up in bed once, and that he/she doesn't know why they can't take ten minutes to give him/her a shower. Resident R77's clinical record revealed an admission date of 6/25/25, with diagnoses including bacterial infection in the right ankle/foot bone, amputation of the right leg below the knee, Type 2 Diabetes, Parkinson's and Alzheimer's diseases Resident R77 was scheduled to receive his/her shower/bath on Wednesday and Saturday nights. Further review of Resident R77's clinical record revealed he/she had received two bed baths in the last 30 days. During an interview on 6/10/26, at 11:23 a.m. Resident R77 confirmed that he/she has not been taken to the shower/bath area recently and has only been washed up in his/her room. During an interview on 6/12/26, at 9:50 a.m. the Director of Nursing confirmed the facility could not provide additional documentation to support Residents R2, R43, R53, and R77 had received more showers/baths. During an interview on 6/09/26, at 12:55 p.m. Resident R65 reported that he/she has waited up to three hours in the evening and on weekends for his/her call bell to be answered and that he/she has wheeled themselves out to the hallway to seek assistance. Resident R65 also reported that he/she has waited as long as two hours to get put to bed. During an interview on 6/09/26, at 1:07 p.m. Resident R29 reported that he/she has waited two-three hours to have their call bell answered and that it mostly happens on the afternoon shift, and that he/she soiled the bed while waiting for the staff to answer his/her call bell. During an interview on 6/10/26, at 10:34 a.m. Resident R42 reported that his/she waits way too long for the call bell to be answered, and that it is frustrating when you have been waiting at least an hour and when staff finally do come in you are told that you now have to wait until someone goes to break. He/she confirmed this most often happens on the second shift. During a resident council meeting n 6/10/26, from 11:00 a.m. to 11:45 a.m., it was confirmed by all resident's in attendance (Resident R21, Resident R23, Resident R32, Resident R44, and Resident R66) that call bell wait times are excessive and the average wait time is over 30 minutes on a consistent basis. All residents also identified that morning and evenings before bed are the longest call bell waits.Resident R44 stated that he/she has waited over 2 hours. Resident R23 stated that employees come in the room and turn the call bell off after waiting over 30 minutes and then residents have to ring again and wait for assistance. Resident R23 also stated that if they don't answer call bell, he/she has to blow a whistle to get attention. Resident R23 also has called the front desk to get someone to please answer call bell and assist self or roommate R21. Resident R32 stated that he/she waited until after noon to get assistance out of bed in the morning. Resident R32 called for assistance and did not get help all morning. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(d)(1)(4)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to discard outdated insulin on two of four medication carts and failed to prevent the opportunity for unauthorized access of medications on one of four medication carts. Findings include: A facility policy entitled Storage of Medications dated [DATE], indicated discontinued, outdated, or deteriorated drugs or biologics are returned to the dispensing pharmacy or destroyed; and compartments (including drawers, carts) containing drugs and biologics are locked when not in use, and unlocked medication carts are not left unattended. A facility policy entitled Insulin Pen Storage Policy dated [DATE], indicated that a beyond-use dating label will be assigned to the cartridge (28 days or manufacturer's expiry, whichever is first), check the cartridge's insulin type and expiry before each use. Observation on [DATE], at 3:11 p.m. revealed that Building One Back Hall medication cart was located in the hallway and was unlocked and left unattended. During an interview on [DATE], at 3:19 p.m. Registered Nurse Employee E2 confirmed that the Building One Back Hall medication cart should have been locked when it was left unattended. Observation on [DATE], at 4:02 p.m. revealed Building Two [NAME] medication cart contained a multi-dose injection pen of Lantus (long-acting insulin used to control high blood sugar in adults and children with diabetes mellitus) labeled for discard date of [DATE]. During an interview at that time Licensed Practical Nurse (LPN) Employee E4 confirmed that the multi-dose injection pen was expired. Observation on [DATE], at 4:10 p.m. revealed Building One Front Hall medication cart contained a multi-dose injection pen of Humalog (man-made analog of natural insulin, designed to act quickly in the body) label with an open date of [DATE], and discard date of [DATE]. During an interview at that time LPN Employee E3 confirmed that the multi-dose injection pen was expired. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to hospice services for one of four hospice residents reviewed (Resident R13). Findings include: Review of a hospice facility agreement dated 5/23/26, revealed the following:The Interdisciplinary Team with Nursing Facility representatives and the Nursing Facility Attending Physician shall review and revise the individualized Plan of Care as frequently as the resident/patient's condition requires, but no less frequently than every 15 calendar days.Hospice shall provide the Nursing Facility Designee with a copy of the most recent Plan of Care specific to each resident/patient.Nursing Facility and Hospice shall each prepare and maintain complete, accurate, and detailed clinical records concerning each resident/patient.All entries made for services provided hereunder are to be legible, clear, complete, and appropriately authenticated and dated in accordance with applicable policy and currently accepted standards of practice. Resident R13's clinical record revealed an initial admission date of 11/11/25, with diagnoses that included Parkinson's Disease (disorder of the nervous system that causes nerve cells in parts of the brain to weaken, become damaged, and die, and can lead to difficulty walking, talking, or completing everyday tasks), dementia, depression, and high blood pressure. The clinical record revealed a physician's order dated 1/07/26, that indicated Resident R13 was admitted to hospice services. Further review of Resident R13's clinical record revealed the most recent plan of care included an end date of 5/06/26 and wasn't updated; and the most recent hospice visit notes (communication sheets) were dated 5/12/26 and no more current visit notes. During an interview on 6/11/26, at 10:50 a.m. the Director of Nursing confirmed Resident R13's clinical record lacked evidence that the hospice care plan was current/updated and that hospice visit notes/communication sheets were current. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.5(f) Medical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and failed to maintain sanitary conditions in one of two resident refrigerators (Building One). Findings include: Review of facility policy entitled Use and Storage of Food Brought to Residents By Visitors, dated 4/16/26, revealed that Visitors may bring food to our residents upon their request; Any food brought into the facility for onsite consumption must be in ready-to-eat form; Food or beverage in the original containers that is beyond the manufacturer's expiration date will be discarded by nursing staff. Observation on 6/10/26, at 10:50 a.m. of the building one refrigerator used for residents revealed two individual containers of yogurt with manufacturer's expiration dates of 5/28/26 and 5/31/26, and a brown sticky substance covering the shelf of the refrigerator. During an interview on 6/10/26, at the time of observation Registered Nurse Employee E5 confirmed the resident refrigerator in building one was not clean and contained two single serve yogurt containers that were expired and should be discarded. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of the facility's arbitration agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and/or resident representative and facility agree on the selection of an arbitrator and venue. Findings include: Upon review of the facility's arbitration agreement for who will conduct the arbitration, the arbitration agreement lacked evidence addressing that the selected venue would be convenient to both the resident and/or resident representative and the facility. During an interview on 6/12/26, at 11:20 a.m. Nursing Home Administrator confirmed the language of the arbitration agreement does not provide for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue that is convenient to both parties. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of clinical records and facility policy, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during the administration of medications through a gastrostomy tube [G-tube (a surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach for individuals who cannot eat enough by mouth)] for one of five residents observed during medication administration (Resident R38).Findings include:A facility policy entitled Enhanced Barrier Precautions (EBP (infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms [MDROs] in healthcare settings) dated 4/16/26, indicated that EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply; and examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (feeding tube [g-tube/peg tube]).Resident R38's clinical record revealed an admission date of 9/09/24, with diagnoses that included stroke with left-sided weakness, mild cognitive impairment, aphasia (language disorder that affects your ability to speak and understand what others say), and muscle wasting. The clinical record also revealed a physician's order dated 4/24/25, for EBPs for peg tube every shift. Observation on 6/10/26, at 8:20 a.m. revealed that Licensed Practical Nurse (LPN) Employee E3 administered Resident R38's medications through his/her g-tube and failed to don a gown prior to administering the medications.During an interview on 6/10/26, at 8:25 a.m. LPN Employee E3 confirmed he/she didn't believe they had to wear a gown to administer medication through a g-tube.During an interview on 6/11/26, at 10:55 a.m. the Director of Nursing confirmed that LPN Employee E3 should have worn a gown to administer medications through a g-tube. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, facility incident reports, facility documents, and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair resulting in harm of a fractured orbital bone (a bony cavity in the skull that houses and protects the eyeball) for one resident reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse and Neglect dated 4/16/26, revealed Neglect.means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait and mobility, weakness, difficulty in walking, hypertension (high blood pressure), dysphagia (difficulty swallowing), and lack in coordination. Review of the clinical record revealed that Resident R1 had a BIMS (brief interview for mental status) score of seven. The BIMS tool is used to assess cognitive function; a score of seven indicates a severe impairment. Nursing progress notes revealed that on 4/12/26, at 4:08 p.m. Resident R1's family member was pushing him/her outside in his/her wheelchair and staff educated at that time in relation to the importance of utilizing leg rests to prevent injury. Review of information dated 4/16/26, submitted by the facility to the Department of Health, revealed the following: Resident R1 was being pushed to the dining room, leaned forward, fell out of wheelchair and hit his/her head. sent to emergency department.occipital fracture . plan for therapy to add wheelchair leg rests at all times. Review of the initial facility incident report dated 4/16/26, revealed a staff description that Resident was being pushed up the ramp in a wheelchair when the resident fell face forward out of the wheelchair. Review of a facility document entitled NAs (Nursing Assistants) and Therapy Orientation Information indicated that equipment should be checked for safety and accuracy, i.e. leg rests in place. Review of facility orientation documents upon hire for NA Employee E1 revealed he/she received training related to safe transfers on the NA job competency orientation checklist 1/26/26, abuse/neglect 1/27/26, and acknowledgement to CNA duties on 1/27/26. Interview with the Registered Nurse Supervisor Employee E2 on 5/6/26, at 10:45 a.m. revealed that no matter what staff should always utilize leg rests during all transports when a resident utilizes a wheelchair. Interview conducted on 5/6/26, at 10:55 a.m. with the Director of Therapy revealed that it is the standard at the facility to utilize leg rests during all transport when a resident utilizes a wheelchair, and that staff are educated upon hire and throughout the year. Interview conducted on 5/6/26, at 12:01 p.m. with NA Employee E1, the staff member involved in the incident, revealed that Resident R1 had his/her leg rests on his/her wheelchair and that [the resident] was putting his/her right foot under the leg rests. Therefore, NA Employee E1 removed the leg rests and proceeded to push Resident R1 up the ramp to the dining area, when Resident R1 suddenly stiffened and fell forward out of the wheelchair. During an interview with the Director of Nursing (DON) on 5/6/26, at 2:29 p.m. he/she confirmed that during the transport on 4/16/26, Resident R1's wheelchair leg rests were not in place, causing Resident R1 to fall from his/her wheelchair and sustaining harm of a fractured orbital bone. The DON also confirmed that leg rests should always be in place when transporting a resident in a wheelchair. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.10 (c) Resident care policies

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program for one of two buildings that residents reside (Building One). Findings include: No facility policy provided. Observations on 4/13/26, at approximately 11:00 a.m. revealed seven windows open with no screens throughout Building One. During the time of observations, the Maintenance Director confirmed that the facility did not have screens for any windows, including the seven windows that were observed open in the facility. Interviews with Residents R1, R2, and R3 on 4/13/26, at 11:45 a.m. through 12:20 p.m. revealed that a snake was observed in a resident's room and hallway of Building One the evening of 4/09/26. Resident R1 and R2 further indicated that the snake likely came in through an open window due to no screens in the window, allowing pests to enter freely. Interview with the Nursing Home Administrator (NHA) on 4/13/26, at 2:35 p.m. confirmed that a snake was in the building on 4/09/26, and the facility was unaware of how the snake got in the building. The NHA further confirmed that windows can be readily opened throughout the facility, and the facility lacks screens for the windows of Building One and Building Two that could allow pests to enter through those areas. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to implement resident-directed care and treatment consistent with professional standards of practice, for one of six residents reviewed (Resident R1).Findings include: Review of a current facility policy entitled Verbal Orders indicated a verbal order will not be written that is not based on a conversation with the practitioner. Resident R1's clinical record revealed an admission date of 9/23/25, with diagnoses including respiratory failure, pneumonia (viral or bacterial infection of the lung), difficulty swallowing, artificial right knee, and altered mental status. The clinical record also revealed a verbal physician's order dated 10/30/25, and signed by the physician on 10/31/25, for staff member present with resident during meals. Small bites & small sips. Review of Resident R1's hospital discharge orders dated 10/30/25, lacked evidence of orders to include for staff member present with resident during meals, small bites and sips. Review of Resident R1's clinical record indicated that he/she was evaluated and treated by Speech Therapy from 10/31/25, to 11/26/25, There was no evidence of a Speech Therapy recommendation and/or a conversation with the provider prior to the order dated 10/30/25, to have staff member present during meals, small bites and sips. Observation on 12/17/25, at 12:29 p.m. revealed staff placed Resident R1's lunch meal on his/her tray table and left the room, at 12:33 p.m. Resident R1 was observed using a fork to feed himself/herself without difficulty and without a staff member present. Observation and confirmation on 12/17/25, at 12:43 p.m. with the Director of Nursing (DON) confirmed that Resident R1 was sitting up in bed feeding himself/herself alone. During an interview on 12/17/25, at 2:30 p.m. the DON confirmed that Resident R1's order for staff member present with resident during meals, small bites and sips was not based on Speech Therapy recommendations, and that there was no evidence that staff consulted the medical provider prior to writing the verbal order, and that the order was entered in the clinical record in error. 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 facility policy, job descriptions, resident council minutes and grievances, and resident, family, and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for eight of eight residents interviewed (Residents R9, R32, R35, R37, R48, R49, R60, and R63). Findings include: Review of facility policy entitled, Answering the Call Light dated 1/20/25, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure - 1 Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2 If assistance is needed when you enter the room, summon help by using the call signal. 3 When answering a visual request for assistance (light above the room door), knock on the room door. When the resident responds, address the resident by his/her name (e.g., How may I help you, Mr. [NAME]?). Review of facility job descriptions for a Certified Nursing Assistant (CNA) indicated, The purpose of Your Job Position - To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Customer Service & Resident Rights - Ensures that call lights are answered by all employees of the facility regardless of department. If you are not trained to assist with request/need then inform resident that you will seek appropriate personnel immediately, then do so. During an interview on 6/23/25, at 4:15 p.m. Resident R9's family member indicated that his/her family member's call bell can be on for an hour at a time, and when he/she visited on the weekend, he/she counted 13 call bells on down the hallway, and no staff were observed answering them or available to answer them. Interviews during the resident council meeting on 6/24/25, between 11:00 a.m. and 12:00 p.m., revealed resident concerns with staff not responding to their call bells timely. Eight of eight alert and oriented residents in attendance indicated that it takes 45 minutes to over an hour for call bell response, further indicating it is worse on the weekends. Resident R35 stated they answer his/her call bell and they say they will come back and they never do or they will tell him/her that they are not their aide and they will get his/her aide for them and they never do. Resident R49 stated when someone answers their call bell they must shut it off and not tell anyone because they say they will send an aide in and no one ever shows up. Resident R60 stated it is not uncommon to have to wait a hour to an hour and a half to get a response. The other residents in attendance agreed with statements made by Residents R35, R49, and R60. Review of resident council minutes from April, May, and June of 2025, revealed the following: April 2025 resident council minutes revealed residents stated when they need assistance the aide stated that they are not their aide for the day and do not help them. May 2025 resident council minutes revealed aides are walking past resident rooms when being flagged down by the resident and when residents' need help, the aides will state they are not their aide. Review of the grievance logs from January, February, March, April, May, and June of 2025 revealed grievances related to call bell response time: January 2025-waiting 30 minutes for call bell response. February 2025-waiting two hours to have call bell answered and waiting a long period of time on the toilet for staff to respond. March 2025-waiting one hour for morning aide. April 2025-aides telling residents they are not their aide and call bells not being answered June 2025-waiting one and a half hours to be put to bed, staff answering call bell and stating they will be back and not returning During an interview with the Corporate Nursing Home Administrator, Corporate Registered Nurse, and Director of Nursing on June 26, 2025, at 2:30 p.m. they confirmed that the resident council minutes and grievance log revealed call bell concerns and had no further information to provide that addressed the above staffing related concerns. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety, failed to label food brought into the facility with the resident's name and use by date, and failed to maintain sanitary conditions in one of two resident refrigerators (Building 1). Findings include: Review of facility policy entitled Foods Brought by Family / Visitors, dated 1/20/25, revealed that Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date, Nursing staff will discard perishable foods on or before the use by date, The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). Observation on 6/26/25, at 10:15 a.m. of resident freezer in Building 1 revealed the following: Stouffers Spaghetti with staff name and no date; [NAME] pie crust with no name and expiration date of 12/24/24; and bag of frozen carrots and peas, 20 ounce bottle of Pepsi, ice cream cake, salmon, and individual cheese and pepperoni pizza with no name and no date. Observation on 6/26/25, at 10:19 a.m. of resident refrigerator door in Building 1 revealed the following: Plastic cup tipped over that appeared to have a creamy white liquid that spilled in the door, with soaked paper towel noted under the cup, and dried sticky creamy white liquid on the shelf; container of grapefruit with no name and expiration date of 4/20/25; two individual containers of jello with no name and expiration dates of 2/25/25, and 6/3/25; and a container of yogurt with no name and expiration date of 6/7/25. Observation on 6/26/25, at 10:22 a.m. of resident refrigerator shelves in Building 1 revealed the following: three individual containers of jello with no name and expiration date of 5/30/25; a container of gelatin with no name and expiration date of 6/6/25; five individual containers of guacamole with no name and expiration date of 4/27/25; container of pineapple, container of cheesecake, container of a half piece of cheesecake with strawberries, four cartons of eggs, container of crackers and cheese, two packages of string cheese, and a half bag of shredded mozzarella cheese all with no name or date; container of fresh fruit, container of strawberries, container of watermelon, container of potato soup, container of pasta salad, container of mixed fruit, and a takeout container with steak, onions, and french fries all with no date. During an interview on 6/26/25, at 10:27 a.m. Medical Records / Admissions Coordinator confirmed resident freezer/refrigerator in Building 1 was dirty, contained numerous items that were not labeled as required, and/or items that were expired. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policy and clinical records, observations, and interviews with residents, family members, and staff, it was determined that the facility failed to maintain a sanitary, orderly, and comfortable interior/homelike environment for two of 22 residents observed (Residents R9 and R32). Findings include: A facility policy entitled, Homelike Environment dated 1/20/25, revealed Residents are to be provided with a safe, clean, and comfortable environment and encouraged to use their personal belongings to the extent as possible. Resident R9's clinical record revealed an admission date of 11/04/24, with diagnoses that included fracture of left femur (large bone above the knee), post cholecystectomy syndrome (abdominal symptoms that persist after having the gallbladder removed), high blood pressure, and atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow). Resident R32's clinical record revealed an admission date of 4/20/25, with diagnoses that included cerebral infarction (when blood flow is interrupted and blocked in the brain causing tissue to die), high blood pressure, chronic obstructive pulmonary disease (a group of conditions that block airflow and make it difficult to breathe), and diabetes mellitus (a group of diseases that result in too much sugar in the blood). Observations on 6/23/25, at 4:15 p.m. of Resident R9's and R32's room revealed broken closet doors for both residents, peeled and chipped paint behind Resident R9's bed and chair, and an exposed soiled toilet plunger in their shared bathroom that was resting on a clear wet bag with a brown substance on bottom of plunger and bag. Interviews with Resident R9 and his/her family member, and Resident R32 on 6/23/25, at 4:15 p.m. revealed the closet doors have been broken for quite some time, the peeled-chipped paint has been a concern since Resident R9 was admitted , and the toilet plunger in the shared bathroom has always been there uncovered and exposed, due to the toilet has concerns with being plugged often. An interview on 6/24/25, at 3:00 p.m. with the Infection Control Nurse confirmed that Resident R9 and R32's closet doors were broken, the wall behind Resident R9's bed and chair was observed with peeled and chipped paint, and an exposed unsanitary toilet plunger was in Resident R9 and R32's shared bathroom. The Infection Control Nurse further confirmed that the facility failed to provide a sanitary and homelike environment for Residents R9 and R32. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3) Management

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for two of three residents reviewed with facility-initiated transfers (Resident R12 and Closed Record Resident CR75). Findings include: A facility policy entitled Transfer or Discharge, Emergency dated 1/20/25, revealed should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures.Prepare a transfer form to send with the resident. Resident R12's clinical record revealed an admission date of 6/23/21, with diagnoses that included high blood pressure, diabetes (a health condition caused by the body's inability to produce enough insulin), and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R12 was transferred to the hospital on 2/6/25. Resident CR75's clinical record revealed an admission date of 3/19/25, with diagnoses that included muscle wasting and atrophy (wasting away of muscle tissue), muscle weakness, dysphagia (difficulty swallowing), and difficulty walking. Resident CR75 was transferred to the hospital on 3/25/25. Residents R12 and CR75's clinical records revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, to include the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. An interview with the Corporate Compliance Registered Nurse on 6/26/25, at 1:30 p.m. confirmed Resident R12 and CR75's clinical record did not contain the required information prior to transferring to the hospital. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

Based on review of facility policy and Quality Assurance meeting attendance records, and staff interviews, it was determined that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all required committee members for two of four quarters (October 2024 and January 2025). Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership dated 1/20/25, indicated the quality assurance and performance program is overseen and implemented by the QAPI committee, which reports its findings, actions, and results to the administrator and governing body. The following individuals serve on the committee: Administrator, or a designee who is in a leadership role, Director of Nursing Services, Medical Director, Infection Oreventionist (nurse certified in Infection Control and Prevention), and Representatives of the following departments, as requested by the administrator: Pharmacy, Social Services, Activity Services, Human Resources, and Medical Records. The committee meets at least quarterly (or more often as necessary). Review of facility's QAPI Committee Meeting Attendance Records from July 2024, to June 2025, revealed the facility failed to have an Infection Preventionist in attendance for the October 2024, and the January 2025, meetings as required to attend at least quarterly. The Corporate Nursing Home Administrator confirmed on 6/27/25, at 2:41 p.m. that there was no evidence the Infection Preventionist attended the October 2024, and January 2025, QAPI meeting. The facility failed to have all the required QAPI committee members present at least quarterly as required. 28 Pa. Code 201.18 (e)(1)(2) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 22 residents observed. (Resident R44) Findings include: Review of the facility policy entitled, Call system, Residents with a policy review date of 1/20/25 , revealed that residents are provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Observation of building two during medication pass on 6/23/25, at approximately 5:30 p.m. revealed Resident R44 was sitting in a bedside chair with no call bell to alert staff for assistance if necessary. Upon checking the room for the call bell cord, it was observed that there was no call bell plugged into the wall for Resident R44's bed and no call bell observed in the room. During an interview with Licensed Practical Nurse Employee E1, at the time of the observation, it was confirmed that there was no call bell for Resident R1 and no way for Resident R1 to alert staff for assistance. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on review of clinical records, facility policy and documentation, and staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of one residents reviewed who eloped from the facility (Resident R1). Findings include: Review of the facility policy entitled, Safety and supervision of residents, with a policy review date of 1/20/2025, revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety address risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring and reporting process. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included traumatic subdural hemorrhage without loss of consciousness (Bleeding between the brain and its outermost covering), mild cognitive impairment (confusion), chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breathe), type 2 diabetes (condition in which the body has difficulty controlling blood sugar and using it for energy), repeated falls, anxiety, depression, and nicotine dependence. A Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 4/22/2025, identified Resident R1 with a Brief Interview for Mental Status (BIMS-a type of test to determine one's level of cognition) score of 14 and cognitively intact. During an initial interview on 4/29/2025, at 10:45 a.m. the Director of Nursing (DON) and the Nursing Home Administrator (NHA), confirmed that on Friday 4/25/2025 at approximately 7:30 p.m. Resident R1 exited the facility without staff awareness by unlocking the door and leaving the front porch and leaving the facility property. Resident R1 traveled down the street with assistance of a walker. The DON referenced that Resident R1 was alert and oriented and goes out on the front porch sitting area often. He/she was out of cigarettes and therefore left the facility to go to the store and buy a pack of cigarettes. Upon request, the facility was unable to provide a smoking policy. It was then confirmed by the NHA and DON that the facility is a tobacco free and non-smoking facility. Review of progress notes revealed the following documentation: On 4/19/25, at 11:53 a.m. Activities came and made this nurse aware that she caught resident smoking in the hall by the back door. This nurse went in and made resident aware that he is not allowed to smoke in the facility due to the oxygen and this being a non-smoking facility. Resident verbalized understanding and stated, 'well if you guys would allow me outside to smoke, I'd just have one.' This writer made him aware that upon admission he had to sign a paper agreeing to this being a non-smoking facility. This writer was able to get lighter and cigarettes from resident. They are in med cart. Spouse made aware. She stated 'She will pick them up just don't know when' she was also made aware that this facility is a non-smoking facility and she is to not bring any tobacco products. She apologized and verbalized understanding. Resident is very upset in room, continuing to self-transfer. On 4/23/2025 at 1:10 a.m. Resident out at Nurses station C/o [complains of] not being able to smoke and was told it was facilities rule that it is a non-smoking building. He also stated that on 3-11 shift he had asked for Tylenol and had to wait a half an hour to receive it but refused when it was brought to him because it had taken too long. After explaining the smoking policy to him he said that the topic was not over yet and that he was told this a.m. that he could smoke a cigarette but then the nurse who gave it to him could not find a lighter and the cigarette was taken back from him for this reason. He also said that someone had told him that the administrator was coming to see him but did not show up. When I first informed him of the policy he said he was going to stand in front of it all night. To try and calm him down I offered him a cup of coffee and a CNA [certified nurse aide] got his w/c [wheelchair] from his room so he could have a seat and he sat and just generally conversed about all different things to get his mind off of what he was upset about and after awhile stated 'Well I am not going to take it out on you people just doing your job' and then went to bed. Review of Resident R1's MDS Section E Behaviors dated 4/22/2025, revealed under section E0900 wandering presence and frequency- Has the resident wandered? with response of 0-Behavior not exhibited. An interview was conducted with Resident R1 on 4/29/2025, at 11:25 a.m. Resident R1 was in the lobby sitting in a wheelchair with a pack of cigarettes and a lighter on his lap, waiting to go outside on the front porch. During the interview, Resident R1 identified that he did leave the building on April 25, 2025, at approximately 7:30 p.m. Resident R1 stated that he was out of cigarettes, and needed to smoke, he could not get a cigarette from anybody. He knew where the door button was under the nurse's station desk, he leaned over the desk, pushed the button to open the door and went outside with his walker opened the gate on the front porch and went down the street to find a store to buy cigarettes. He stated that an employee noticed him standing by the side of the road who gave him a ride back to the facility. He stated that the facility lets him outside to smoke and keeps his cigarettes and lighter locked in the medication cart. When he needs a cigarette he asks, they give him his lighter and cigarettes and let him out to smoke on the porch. He stated he knew where the button to unlock the door was because he had seen it done before. Resident R1 stated he had never tried to leave the facility property without somebody knowing before. He stated that the DON did speak with him about not leaving the facility, and safety issues and the facility non-smoking policy. When asked if he would try to leave again, Resident R1 stated, If I need a cigarette I will. I am an adult, they cannot hold me here against my will. There was no evidence that Resident R1 had any safety interventions in place regarding smoking habits until after the elopement had occurred on 4/25/2025. There was no evidence that the facility completed a safe smoking assessment to provide safety and prevent injury to Resident R1. Review of progress notes lacked any documentation on 4/25/2025, regarding the elopement until the investigation on 4/29/2025. Review of care plans revealed no updates to care plans regarding elopement risk or smoking safety from the date of the elopement on 4/25/2025, to investigation on 4/29/2025. At the time of investigation on 4/29/2025, there were no elopement prevention interventions in place for Resident R1 An interview with Licensed Practical Nurse (LPN) Employee E1 on 4/29/2025, at 11:35 a.m. revealed that Resident R1's lighter and cigarettes were kept in the medication cart in the locked drawer. When he wants a cigarette, he asks and was given his cigarettes to go out and smoke. A telephone interview on 4/29/2025, at approximately 11:50 a.m. with the Registered Nurse (RN) Supervisor who had been on duty the evening of the elopement on 4/25/2025, revealed that Resident R1 was in the lobby and upset that he had no cigarettes. There was nobody at the desk at the time the resident left due to performing resident care in another area of the facility. It was unknown that Resident R1 left the building and went down the street until they were informed by one of the staff that had left after their shift was done and recognized him standing by the road with his walker. He was then brought back to the facility. An Immediate Jeopardy (IJ) situation was identified to the NHA and DON on 4/29/2025, at 2:03 p.m. and the IJ template was provided to the NHA, related to Resident R1's elopement from the facility and smoking safety. The NHA and DON were made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On 4/29/2025, at 6:15 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. Resident will have a smoking assessment completed 4/29/2025. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence. 2. All residents will be assessed for elopement risk by the director of nursing or designee by the end of the day on 4/29/2025. 3. All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the end of the day on 4/29/2025, by the Director of Nursing or designee. 4. Facility is a non-smoking facility and currently all other residents are compliant. 5. A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited. 6. Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee. 7. Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents. 8. Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee by 4/29/2025 9. A protective device will be placed over the exit door button to prevent residents from access. 10. Audits will be implemented to ensure residents are adhering to the facility smoking policy daily for two weeks, weekly for two weeks, and monthly for two months by the Director of nursing or designee. 11. New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed. 12. An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee on 4/29/2025. 13. This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 4/30/2025, at 1:44 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and elopement prevention and safe smoking interventions were effectively implemented in the facility. Findings include: The job description for the NHA revealed that the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The job description for the DON specified to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent elopement for their residents, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and facility documents, and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for two of six residents reviewed (Residents R1 and R2). Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included broken right lower leg, stroke, dementia, and muscle wasting. A departmental progress note dated 4/07/25, revealed that Resident R1 was transported to the hospital for evaluation and treatment of rectal bleeding. Upon return to the facility a physician's order dated 4/07/25, identified to administer Azithromycin (antibiotic) 250 milligrams by mouth daily for four days for treatment of Respiratory Syncytial Virus (RSV- seasonal, highly contagious respiratory virus that often feels like a common cold). Review of Resident R1's April 2025 Medication Administration Record (MAR) revealed that he/she did not start receiving the ordered antibiotic until 4/10/25, (three days late). Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), kidney disease, heart disease, and respiratory failure. Review of a Complaint/Grievance Form provided by the facility on 4/24/25, and dated 3/31/25, revealed a concern that Resident R2 hadn't received a new medication on 3/28/25, through 3/31/25, (four days). Resident R2's departmental progress note dated 3/27/25, revealed that the facility was made aware that a medication as ordered by an outside provider and that the medication would be sent either tomorrow (3/28/25), or Saturday (3/29/25). Review of Resident R2's April 2025 MAR revealed that he/she did not receive the medication until 4/01/25, (four days late). During an interview on 4/24/25, at 1:20 p.m. the Director of Nursing confirmed that Resident R1 and Resident R2's medications were not administered according to physician's orders and were given late. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical records, facility documentation, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for seven of 44 residents reviewed (Residents R1, R2, R3, R4, R5, R6, and R7). Findings include: A facility policy entitled, Activities of Daily Living (ADL), Supporting dated 4/24/24, revealed Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems). Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. appropriate response. Resident R2's clinical record revealed being admitted to facility on 8/11/23, with diagnoses that included muscle wasting and atrophy (decrease of muscles throughout the body), acute respiratory with hypoxia (a condition where there are dangerously low oxygen levels in the blood and lungs), diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), and hypothyroidism (a condition which the thyroid gland does not produce enough thyroid hormone). Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) Assessment Section C - Cognitive Patterns Section C0500 dated 10/11/24, revealed Resident R2 with a BIMS score of 15/15. Resident R2 's MDS 3.0 Section G dated 10/17/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R2 was an extensive assistance with two or more persons physical assist for transfer. During an interview on 10/15/24, at 11:45 a.m., Resident R2 and his/her family member indicated that he/she is often awakened at 3 a.m. to get a shower. Resident R2 stated, I tell them, are you half crazy? I am not getting a shower now .it's the middle of the night. Resident R2's family member stated hospice staff typically give Resident R2 his/her shower thankfully, and the facility staff mark him/her as a refusal due to him/her telling them no since it is at 3 a.m Resident R2's family member further indicated that due to lack of staff, the midnight staff do showers/baths on midnight shift to help the day and afternoon staff. Resident R2 further indicated that he/she now stays in bed throughout the day, due to numerous times of getting out of bed and staying in his/her chair for long periods of time with increasing pain. Resident R2 further indicated he/she is not transferred back into bed from his/her chair timely per his/her desire due to lack of staff. Resident R1's clinical record revealed being admitted to facility on 9/20/2024, with diagnoses that included muscle wasting and atrophy, dysphagia (difficulty swallowing), lack of coordination, and cognitive communication deficit (having difficulty paying attention to conversation, staying on topic, and following directions). Resident R1's MDS Section C - Cognitive Patterns Section C0500 dated 9/23/24, revealed Resident R1 with a BIMS score of 15/15. During an interview on 10/15/24, at approximately 2:00 p.m. Resident R1 indicated that his/her roommate (Resident R7) sometimes waits two hours for his/her call bell to be responded to. At times, Resident R1 indicated he/she will have to go to the nurse's station and get someone to come help his/her roommate due to nobody coming into help him/her. Resident R1 further indicated that his/her roommate cannot get out of his/her bed or chair by himself/herself and needs assistance from staff. Resident R1 also indicated that due to lack of staffing, he/she sometimes must wait until 10 p.m. for a shower, after he/she has already fallen asleep and is then awakened late to get a shower. Resident R7's clinical record revealed being admitted to facility on 8/29/24, with diagnoses that included muscle wasting and atrophy. Resident R7's MDS Section C - Cognitive Patterns Section C0500 dated 9/25/24, revealed Resident R7 with a BIMS score of 15/15. During an interview with Resident R7 (roommate to Resident R1) on 10/15/24, at approximately 2:05 p.m., he/she confirmed Resident R1 (as previously noted in above notation) often goes out of their room to retrieve nursing staff to assist him/her to the bathroom and/or to get in/out of chair or bed. Resident R7 confirmed he/she often waits one to two hours to get assistance when he/she puts his/her call bell on. Resident R7 stated, Waiting two hours to go to the bathroom is just way too long. I just end up peeing in my pants. Resident R3's clinical record revealed being admitted to facility on 9/14/21, with diagnoses that included Alzheimer's disease (a disease of the brain affecting mood, decision making, and behavior), dislocation of left hip, high blood pressure, and protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body). Resident R3's MDS Section C - Cognitive Patterns Section C0500 dated 8/12/24, revealed Resident R3 with a BIMS score of 99 due to resident is rarely/never understood and unable to complete interview. Resident R3's MDS 3.0 Section G dated 8/13/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R3 was an extensive assistance with a two or more persons physical assist for transfer. Resident R3's physician orders dated 6/04/24, revealed resident to be out of bed to broda chair (type of positioning chair) for lunch and dinner. Observations on 10/15/24, at 11:28 a.m., 12:10 p.m. and 3:15 p.m. revealed Resident R3 laying in bed on his/her left side. Resident R3 was not observed out of bed for lunch on 10/15/24. Resident R4's clinical record revealed being admitted to facility on 9/09/24, with diagnoses that included muscle wasting and atrophy, hemiplegia (partial or total paralysis on one side of body) and hemiparesis (muscle weakness or partial paralysis of one side of the body) following cerebrovascular disease affecting left non-dominant side, open wound of lower back and pelvis, and mild cognitive impairment. Resident R4's MDS Section C - Cognitive Patterns Section C0500 dated 10/18/24, revealed Resident R4 with a BIMS score of 15/15, cognitively intact. Resident R4's MDS 3.0 Section G dated 10/17/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R4 was an extensive assistance with a two or more persons physical assist for transfer. Observations on 10/15/24, at 11:35 a.m., 12:20 p.m. and 2:40 p.m. revealed Resident R4 laying in bed on his/her back. Resident R5's clinical record revealed being admitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy, diabetes mellitus, ulcerative colitis (a chronic inflammatory bowel disease), and depression. Resident R5's MDS Section C - Cognitive Patterns Section C0500 dated 8/07/24, revealed Resident R5 with a BIMS score of 13/15. Resident R5 's MDS 3.0 Section G dated 8/08/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R5 was an extensive assistance with a two or more persons physical assist for transfer. Observations on 10/15/24, at 11:30 a.m., 12:15 p.m. and 3:20 p.m. revealed Resident R5 laying in bed on his/her back. Resident R6's clinical record revealed being admitted to facility on 11/17/23, with diagnoses that included kidney disease, high blood pressure, adult failure to thrive (a gradual decline in a person's physical and mental health), and atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow). Resident R6's MDS Section C - Cognitive Patterns Section C0500 dated 8/22/24, revealed Resident R6 with a BIMS score of 15/15, cognitively intact. Resident R6's MDS 3.0 Section G dated 8/27/24, - Functional Status (Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) revealed Resident R6 was an extensive assistance with a two or more persons physical assist for transfer. Observations on 10/15/24, at 11:28 a.m., 12:55 p.m. and approximately 3:30 p.m., revealed Resident R6 in bed laying on his/her back. An interview with Resident R6 on 10/15/24, at 2:15 p.m. indicated that he/she is reluctant to get out of bed due to sometimes he/she must sit in his/her chair for long periods of time, due to staff being too busy to get him/her back in bed. Resident R6 further indicated that he/she cannot sit in chair for long periods of time due to severe back pain, but enjoys getting out of bed if it is not for extended periods of time. During an interview on 10/15/24, at approximately 3:40 p.m. the Interim Director of Nursing (DON) confirmed Residents R3, R4, R5, and R6 were in bed laying as noted above, as they were observed earlier throughout day. The DON confirmed that residents should be turned/repositioned often and offered to get out of bed. 28 Pa. Code 211.12 (d)(4)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(3) Management

Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received rib fractures that required medical treatment at a hospital for one of one residents reviewed (Resident R1). Findings include: Review of the facility policy, SRC-Safety-17.35 Transfers-ABC, dated 5/12/23, indicated to assist residents with movement from one surface to another .(1) verify resident's mobility needs .(3) determine the necessary amount of assistance needed in accordance with the plan of care. Review of the Job Description Professional CNA (Certified Nurse Assistant) revealed that the nurse aide will provide routine resident care and support services in accordance with established policies and procedures . Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included but not limited to breathing issues, osteoporosis (decrease in bone mass), high blood pressure, anxiety, depression and repeated falls. Review of Resident R1's initial Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated [DATE], revealed that Resident R1 was alert and oriented and his/her transfer status was an extensive assist, two-person physical assist. Review of the Physical Therapy Evaluation- Functional Evaluation MDS section revealed Resident R1 was a maximal assist of two for transfers bed to and from wheelchair. Review of the Potential for injury, trauma, falls care plan revealed Resident R1's transfer status was an assist by two persons. The Kardex (reference document for staff to know provision of care information) revealed Resident R1 was a transfer assist with two persons. Review of an incident report dated 2/05/24, at 6:48 p.m. revealed that Resident R1 complained of right rib pain and stated that the pain started after being transferred to their chair this morning. The resident had no falls or injuries recently. Resident R1's statement, written by the Director of Nursing on 2/05/24, revealed that Resident R1 stated the Nurse Aide bear hugged the resident to transfer the resident from bed to chair and later in the day was experiencing pain. Review of a nurse's note dated 2/05/24, at 6:48 p.m., by Licensed Practical Nurse (LPN) Employee E1 revealed that Resident R1 stated that one of the girls was picking Resident R1 up and putting Resident R1 in their chair and Resident R1's ribs hurt. The LPN Employee E1 spoke with the resident and offered Tylenol. After family came in to visit and Resident R1's family member approached the nursing desk and stated that Resident R1 was complaining of rib pain and inquired whether Resident R1 had been checked and requested an x-ray. Nursing note written by LPN Employee E1 at 8:10 p.m stated x-ray in at 7:45 pm. LPN Employee E1 wrote at 10:44 p.m. that at 9:22 p.m. x-ray results revealed that there were minimal buckle fractures of the lateral right third and fifth ribs and no acute fracture on the left rib cage. Review of a nurse's note dated 2/06/24, at 1:08 p.m. by LPN Employee E2 revealed Resident R1 was medicated for rib pain. Family called into the facility and requested Resident R1 be seen at the emergency room for evaluation and treatment of right rib fractures. Resident R1 was sent to the emergency room at 12:55 p.m. Review of the hospital Discharge Summary report dated 2/06/24, at 5:21 p.m. revealed that Resident R1's reason for the visit was broken ribs. Review of nurse's note dated 2/06/24, at 6:54 p.m. by LPN Employee E3 revealed Resident R1 returned to the facility. On the left side of chest there were mid lateral fractures of the fourth and fifth ribs with mild angulation. Review of a CT-scan completed at the hospital on 2/06/24, revealed there were subtle non-displaced fracture of the lateral left fourth and fifth ribs. Review of the Documentation Supervisor Counseling form conducted with Nurse Aide (NA) Employee E4, dated 2/07/24, revealed NA Employee E4's statement was that they did not look at the transfer status and that other people transfer Resident R1 with an assist of one. Review of information submitted by the facility dated 2/12/24, identified that Resident R1 is identified as a two-person assist with transfers and was transferred by only one staff. During an interview on 2/28/24, at 9:30 a m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility failed to provide a safe transfer that resulted in actual harm of rib fractures to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records, facility documentation, facility policy, hospital records, and staff interviews, it was determined that the facility failed to follow professional standards and update the physician timely for appropriate care and services for a resident with a worsening left lower leg condition, that resulted in actual harm of significant blood loss requiring outside surgical/medical interventions for one of four residents reviewed (Resident R1). Findings include: The Physician Notification policy, dated 4/24/19, revealed that if the clinical findings are urgent, notify the physician. The admission record for Resident R1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R1's clinical record revealed a care plan dated 3/26/19, for being at risk for bleeding from the use of [MEDICATION NAME] (medicine that reduces the risk of blood clots), that Resident R1 was on Aspirin (medicine that reduces the risk of blood clots) and that any new bruising needed to be reported to the health care provider. An investigative report dated 7/26/19, for the hematoma (collection of blood caused by a break in a blood vessel) on Resident R1's left lower leg revealed that on 7/23/19, at 9:00 p.m. Nurse Aide (NA) Employees E1 and E2 were going to give Resident R1 a shower. NA Employees E1 and E2 noticed a big bubble on his/her left lower leg before showering Resident R1. After the shower, Registered Nurse (RN) Employee E3 noticed some discoloration on Resident R1's left lower leg. Around 11:00 p.m. RN Employee E3 looked at Resident R1's left lower leg and noticed a large hematoma. An incident report by Licensed Practical Nurse (LPN) Employee E4 dated 7/24/19, referred to an incident that happened on 7/23/19, at 11:45 p.m. but was noticed on 7/23/19, at 9:00 p.m. by NA Employees E1 and E2, revealed that Resident R1's left lower leg had a hematoma measuring 9 centimeters (cm) by 4 cm. In addition, it revealed that the physician was faxed a copy of the incident report on 7/24/19 at 12:00 a.m. A progress note from LPN Employee E4 on 7/24/19 at 5:11 a.m., stated that the hematoma on Resident R1's left lower leg now measured 10 cm by 6 cm. A progress note from RN Employee E5 dated 7/24/19 at 10:00 a.m., stated that Resident R1's left lower leg had a hematoma measuring 27 cm x 15 cm and was firm and tender to the touch and there was a small amount of pink tinged fluid draining from the area. Resident R1 was getting ready to go to [MEDICAL TREATMENT] and RN Employee E5 placed a loose dressing on left lower leg and stated that he/she instructed resident to be careful, not to bump leg on anything. A report from the local ambulance service who picked Resident R1 up for [MEDICAL TREATMENT] on 7/24/19, at 9:46 a.m. stated that upon arrival to the facility, his/her left lower leg was bleeding. In addition, the report stated that Resident R1 lost 1000 milliliters of blood onto the floor of the wheelchair van during transport. At 10:03 a.m. the ambulance service transported Resident R1 to the hospital instead of to the [MEDICAL TREATMENT] center. Reports from the hospital dated 7/24/19, identified that Resident R1 was lethargic and had a large 14 cm laceration and a huge hematoma on the left lower leg with significant blood loss. Resident R1 received a blood transfusion for a hemoglobin (oxygen carrying pigment of red blood cells) of 6.7 (normal range 14 to 17.4 g/dl for men) and hematocrit (volume of red blood cells expressed as a percentage) of 21 (normal range 40 to 54%). Resident R1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Resident R1 was sent to the operating room on 7/29/19, at 4:39 p.m. and the necrotic tissue (death of body tissue) of the left lower leg was debrided (removal of dead tissue from a wound). The total area debrided was around 80 cm. Resident R1 was discharged back to the facility on [DATE]. The facility failed follow professional standards and keep Resident R1's attending physician informed of the worsening condition of his/her left lower leg during a period of more than 13 hours from 7/23/19 to 7/24/19, that resulted in actual harm to Resident R1 of the enlarged hematoma with significant blood loss requiring hospital medical interventions. 42 CFR 483.25 Quality of Care Previously cited 2/07/19, 10/05/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 2/01/18, 10/05/18, 2/07/19, 4/22/19 28 Pa. Code 201.18(b)(1) Management Previously cited 2/01/18, 2/07/19 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management Previously cited 2/01/18 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/05/18, 2/07/19, 4/22/19 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 2/07/19