Every finding on record at Beaver Valley Rehabilitation and Healthcare Center

Based on a review of facility policies, observations, and staff interviews it was determined that the facility failed to properly date, and store food products, and failed to verify the chemical sanitation of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness.Findings Include: Review of the facility policy Food Receiving and Storage dated 12/22/25, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled, and dated. Review of the facility policy Dishwashing Machine Use dated 12/22/25, indicated that dishwashing machine chemical sanitizer concentration should be Chlorine 50-100 ppm (parts per million) During an interview on 8/10/26, at 8:10 a.m. Dietary Manager Employee E16 stated that the facility's dish machine operated via chemical sanitation. During an observation and interview in the Main Kitchen Dry Storage area, on 8/10/26, at 8:15 a.m. an opened jar of honey was not labeled with the date that it was opened to ensure proper food rotation and safety. Dietary Manager Employee E16 confirmed the above findings. During an observation and interview in the Main Kitchen walk-in freezer, on 8/10/26, at 8;18 a.m. two bags of broccoli, one bag of sugar snap peas, and one bag of cauliflower were not labeled with a receive date to ensure proper food rotation and safety. Dietary Manager Employee E16 confirmed that the facility failed to properly store and label food in the walk-in freezer. During an observation and interview in the Dish Room on 8/12/26, at 9:05 a.m. staff was in process of washing the breakfast dishes. State Agency asked Dietary Aide (DA) Employee E17 if the facility had any test strips to test the chemical concentration of the dish machine to ensure that it was properly sanitizing. DA Employee E17 confirmed that the facility had test strips and proceeded to test the chemical concentration of the dish machine. DA Employee E17 stated It's only ten and it should be between 50-100. [The chemical company] was just here last night'. Dietary Manager Employee E16 proceeded to adjust the positioning of the chemical containers and further inserted the tubing into the chemical solutions to that would disperse the chemicals into the machine. An appropriate reading of the chemical concentration was then obtained. During an interview on 8/12/26, at 9:15 a.m. Dietary Aide Employee E17 confirmed that the facility failed to run a test strip through the dish machine prior to washing dishes to ensure proper sanitation. During an interview on 8/12/26, at 10:02 a.m. Dietary Manager Employee E16 confirmed that the facility failed to verify the chemical sanitation of the dish machine which created the potential for food borne illness. 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(1)Management.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in three of three medications carts (Second-floor South Hall Medication Cart, Second-floor North Hall Medication Cart, and the First-floor South Hall Medication Cart), one of two medication rooms (First-floor Medication Room), one of two emergency crash carts (Second-floor emergency crash cart) and failed to properly secure medications and a medication cart during a medication administration observation for one of three medication carts (Second- floor North Hall Medication Cart). Findings include: Review of the facility policy Storage of Medications last reviewed [DATE], indicated medications and biologicals are stored safely, securely and properly, following manufacturer recommendations of those of the suppliers. Orally administered medications are kept separate from externally used medications, such as suppositories, liquids and lotions. Review of the facility's policy Administering Medications last reviewed [DATE], indicated medications shall be administered in a safe a timely manner. When opening a multi-dose container, the date opened is recorded on the container. The medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be visible to the personnel administering medications. Insulin pens are clearly labeled. Review of the facilities policy Emergency Crash Cart and Automatic External Defibrillators (AEDS) last reviewed [DATE], indicated the emergency crash cart is checked every 24 hours and after every use, Missing or expired items are replaced when applicable. During an observation completed on [DATE], at 9:43 a.m. the Second-floor South Hall Medication Cart contained the following: 1 Humalog insulin quick pen not stored in a bag as required.1 Lantus insulin pen not stored in a bag as required.1 Lantus insulin pen not stored in a bag and not clearly labeled with a date opened as required.1 Lispro insulin pen not stored in a bag and not clearly labeled with a date opened as required.3 opened packages of Ipratropium Bromide inhalation solution opened and not labeled with a date as required.1 bottle lubricating eye drops opened and not labeled with a date as required.2 Trelegy Ellipta inhalers opened and not labeled with a date as required.1 albuterol oral inhaler opened and not labeled with a date as required.1 bottle of nasal spray opened and not labeled with a date as required.1 Anora Ellipta inhaler opened and not labeled with a date as required.1 tube of mupirocin ointment stored with oral medications An unlabeled medication cup that contained half of a white tablet. During an interview completed on [DATE], at 9:58 a.m. Registered Nurse (RN) E6 confirmed the above observations and that the 1/2 white tablet needed to be wasted and at the time another nurse was not available at the time of administration. The Director of Nursing arrived at the floor, confirmed the medication as a tramadol, verified the narcotic count and the waste was then completed and confirmed that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Second-floor South Hall Medication Cart. During an observation completed on [DATE], at 10:01 a.m. the Second-floor Emergency Crash Cart contained: 2 3.7 oz containers of sterile water with the expiration date of [DATE]. During an interview completed on [DATE], at 10:05 a.m. RN Employee E6 confirmed that the containers of sterile water on the Emergency Crash Cart had an expiration date of [DATE]. During a medication administrator observation completed on [DATE], at 9:43 a.m. RN Employee E4 was preparing medications for Resident R75 when it was discovered that the medication cart did not contain a larger size cup that was needed for the [NAME]-Na oral supplement packet. RN Employee E4 left the cup of medications that were prepared on top of the cart, did not lock the medication cart and walked away from the medication cart to retrieve a larger cup. During an interview completed on [DATE], at 10:08 a.m. RN Employee E4 confirmed leaving a prepared medication cup sitting on top of the cart as well as not locking the medication cart and walking down the hall to retrieve larger cups and that the facility failed to properly secure medications and a medication cart during a medication administration observation. During an observation completed on [DATE], at 10:17 a.m. the Second-floor North Hall Medication Cart contained the following: 2 bottles of lactulose liquid opened and not labeled with a date as required.1 bottle of acetic acid opened and not labeled with a date as required.4 boxes of ipratropium bromide and albuterol solution for inhalation opened and not labeled with a date as required.1 Breo Ellipta inhaler opened and not labeled with a date as required.1 Fluticasone powder inhaler opened and not labeled with a date as required.3 bottles of Fluticasone nasal spray opened and not labeled with a date as required.2 Budesonide/formoterol inhalers opened and not labeled with a date as required.2 bottles of red eye relief drop opened and not labeled with a date as required.1 bottle of dorzolamide solution eye drops opened and not labeled with a date as required.1 bottle of brimonidine eye drops opened and not labeled with a date as required.1 box of hydrocort rectal suppository comingling with oral medications.1 tube of Voltaren gel comingling with oral medications. During an interview completed on [DATE], at 10: 25 a.m. RN Employee E4 confirmed the above observations and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the Second-floor North Hall Medication Cart. During an observation completed on [DATE], at 12:28 p.m. the First-floor Medication Room contained:A black tote bag sitting on the counter. The Medication room refrigerator freezer contained:3 blue ice packs. During an interview completed on [DATE], at 12:33 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observations and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the First-floor Medication Room. During an observation completed on [DATE], at 12:33 p.m. the First-floor South Hall Medication Cart contained: A Novolog Flex pen not stored in a bag with the covered needle still attached.A box of bisacodyl suppositories comingling with oral medications. During an interview completed on [DATE], at 12:37 p.m. LPN Employee E2 confirmed the above observations and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in the First-floor South Hall Medication Cart. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R67).Findings include: Review of the facility's policy Administering Medications last reviewed 7/16/26, indicated medications shall be administered in a safe a timely manner. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning has determined that they have the decision-making capacity to do so safely. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/24/26, indicated diagnoses of dysphagia (difficulty swallowing), cognitive communication deficit (a struggle with the mental skills needed to organize thoughts, follow conversations, interpret social cues, or respond appropriately in real-world situations) and right hip fracture. During a medication administration observation completed on 8/12/26, at 9:12 a.m. Licensed Practical Nurse (LPN) Employee E5 was preparing Resident R67's medications. LPN Employee E5 placed the following medications into a medication administration cup:metoclopramide 10 milligram (MG) oral tablet- for nausea/acid refluxOcular Vitamin- supplement eye healthB complex with Calcium D 500/10mg - supplementmagnesium oxide 250 MG Oral Tablet - supplementVitamin C 500mg tablet- supplementTylenol 500mg two tablets- pain/general discomfort LPN Employee E5 prepared another medication cup with two simethicone 80 MG Chewable Tablets and mixed the ordered Miralax into a cup of water. LPN Employee E5 then filled two medication administration cups with pudding, entered Resident R67's room placed the two cups with the medications on her over the bed table as well as the cup that contained the Miralax and the medication cups with the pudding. LPN Employee E5 spoke with Resident R67, handed her a spoon and exited the room. LPN Employee E5 returned to the medication cart and began to prepare medications for the roommate. Resident R67 was observed getting a spoonful of pudding and placing a single medication on top of the pudding and placing into her mouth. LPN Employee E5 re-entered the room, administered medications to the roommate and exited the room. Resident R67 was still placing medications on top of her pudding, the cup of Miralax was still sitting in front of her. LPN Employee E5 proceeded to move her medication cart down the hall to the next room. Upon asking LPN Employee E5 if she had completed the medication pass in room [ROOM NUMBER] she stated yes, she was done. During an interview on 8/12/26, at 9:31 a.m. LPN Employee E5 confirmed giving the medications to Resident R67 for self-administration and not confirming that all the medications were taken prior to moving on to the next room. During an interview competed on 8/12/26, at 10:40 a.m. the Director of Nursing confirmed that the medication cups were left for Resident R67 to self-administer and stated. LPN Employee E5 was receiving current education on medication administration, and a supervisor was accompanying LPN Employee E5 for the remaining medication pass and confirmed the facility failed to determine whether it was safe for Resident R67 to self-administer medications. 28. Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the residents' representatives that a significant alteration in treatment had occurred for two of two residents (Resident R4, and R13). Findings include: Review of facility policy Change in a Resident's Condition or status dated 12/22/25, indicated that the facility shall promptly notify the resident's representative of changes in the resident's medical/mental condition. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to insert a peripheral IV (intravenous)- a short, flexible plastic tube placed into a small surface vein- usually in the hand or arm). Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile salt water solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/26, indicated diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section C0500 indicated a BIMS (Brief interview of mental status) score was 10, indicative of moderate cognitive impairment. Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident. During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. After the interview with the DON, a review of Resident R4's clinical record conducted on 8/13/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/25 12/30/25 1/27/26 2/24/26 3/31/26 4/28/26 5/26/26 6/30/26 Review of Resident R4's clinical record failed to reveal that the resident's family/representative was notified that the resident would have ongoing monthly IV hydration. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's clinical record revealed a physician order dated 7/29/26, to insert a peripheral IV insertion. Review of Resident R13 clinical record revealed a Nutrition Evaluation dated 5/4/26, that resident required 1500-1800 ml of fluid a day, and that the plan is to continue with his plan of care. Review of Resident R13 clinical record revealed a physician order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile saltwater solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R13 MDS dated [DATE], indicated a diagnosis of Non-Alzheimer Dementia (group of brain diseases that mainly affect the frontal and temporal lobes of the brain), Diabetes Mellites (when the body cannot use insulin correctly and sugar builds up in the blood), and depression. Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. Review of Resident R13's clinical record conducted on 8/14/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/25 12/30/25 01/27/26 02/24/26 03/31/26 04/28/26 05/26/26 06/30/26 07/29/26 Review of Resident R13's clinical record failed to reveal that the resident's family/representative was notified that the resident would have ongoing monthly IV hydration. During an interview on 8/14/26, at 1:14 p.m. the DON confirmed that the facility failed to notify Resident R4, and Resident R13's family of a significant change in their treatments. 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of resident's medical information on two of three medication carts (Second-floor South Hall Medication Cart and Second-floor North Hall Medication Cart).Findings include: During an observation on 8/10/26, at 9:40 a.m. the Second-floor South Hall Medication Cart was left unattended at the nursing station, a paper that contained resident names, room numbers and written information was sitting on top of the cart available to anyone passing by. During an interview completed on 8/10/26, at 9:43 a.m. Registered Nurse (RN) Employee E6 confirmed that the Second-floor South Hall Medication Cart was left unattended with resident information sitting on top of it and that the facility failed to maintain the confidentiality of residents' medical information as required. During a medication pass observation completed on 8/11/26, at 10:01 a.m. RN Employee E4 left the Second-floor North Hall Medication Cart unattended to retrieve drinking cups. RN Employee E4 left the computer screen on and visible to anyone passing by. During an interview completed on 8/11/26, at 10:08 a.m. RN Employee E4 confirmed leaving the Second-floor North Hall Medication Cart unattended with the screen on visible to anyone passing by and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on observations and resident and staff interview with was determined that the facility failed to ensure that the grievance policy and process was posted in an accessible place to residents on two of two nursing units (first and second floor nursing care units). Findings include:During observations on 8/12/26, from 9:05 a.m. through 10:02 a.m. on both nursing care units (first and second floor) failed to include the grievance policy and process for grievances. During an interview on 8/12/26, at 1:29 p.m. Nursing Home Administrator confirmed that the facility failed to post the grievance policy and process for grievances in an accessible place to residents on two of two nursing units (first and second floor nursing care units).28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a chair pressure alarm (a device that alerts when pressure is removed that indicates a resident is attempting to stand) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a chair pressure alarm is a restraint for one of two residents (Resident R91).Findings include: Review of facility policy Resident Alarms last reviewed 7/16/26, indicated it is the policy of this facility to utilize resident alarms in limited circumstances. An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means when movement is detected. The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risks, evaluate and analyze risk, implement interventions to reduce risk and monitor the effectiveness of the interventions and modify the interventions when necessary. When alarms are used or are under consideration, risk of adverse consequences related to alarms shall be identified. Alarms shall be initiated only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use. Ongoing assessments of the residents shall occur to identify changes in patterns, routines or medical symptoms. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/9/26, indicated diagnoses of hypertension (high blood pressure), dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and anxiety. Review of Resident R91's physician orders dated 6/11/26, indicated pressure alarm when up in chair every shift for fall prevention check placement and function. Review of Resident R91's care plan initiated on 6/27/25, indicated at risk for falls due to weakness. Interventions that included but not inclusive to chair alarm. Review of Resident R91's clinical record failed to identify any assessments or ongoing evaluations for the use of the chair pressure alarm. During an interview on 8/13/26, at 11:38 a.m. the Director of Nursing confirmed that the facility failed to identify a chair pressure alarm as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a chair pressure alarm is a restraint for one of two residents (Resident R91). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to conduct an FBI background check on personnel prior to working on the nursing unit for one out of five personnel records (Social Worker Employee E22).Findings include: The facility Identifying Types of Abuse dated 12/22/25, indicated that abuse of any kind against residents is strictly prohibited. Review of Social Worker (SW) Employee E22's personnel record indicated she was hired to work at the facility on 4/13/26, and orientation was completed at the facility on 4/13/26. Review of SW Employee E22's personnel record indicated the staff lived outside of Pennsylvania within the past two years. Review of SW Employee E22's personnel record indicated an FBI background check dated 4/27/26. During an interview on 8/11/26, at 2:06 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to conduct an FBI background check on SW Employee E22 prior to working on the nursing unit as required. 28. Pa Code 201.14(a) Responsibility of licensee.28. Pa Code 201.18(b)(1)(e)(1) Management.28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of ten residents (Residents R16 and R84). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025, indicated the following instructions: Section J1300. Current tobacco use Steps for Assessment: 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Section O0110. Special Treatments, Procedures, and Programs Check all of the following treatments, procedures, and programs that were performed. K1. Hospice - mark if indicated while a resident. Review of the facility policy Resident Assessments last reviewed 7/16/26, indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate assessments. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to accuracy of such information. Comprehensive assessment includes completion of the MDS, Completion of the Care Area Assessment (CAA) process and development of the comprehensive care plan. Review of admission record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/26, indicated the diagnosis of hypertension (high blood pressure), traumatic brain injury, and epilepsy (a neurological disorder associated with abnormal electrical activity in the brain marked by sudden episodes of sensory disturbance. loss of consciousness, or convulsions. Section J 1300 Current tobacco used coded 0-No. Review of Resident R16's current care plan initiated 7/19/22, revealed: Safe Smoking: Educate family and visitors not to leave smoking materials in patient's room. Educate to interventions and Facility smoking policy and procedures. Secure smoking materials (cigarettes, matches, lighters, etc.) In medication room Review of Smoking Safety assessment dated [DATE], indicated smoking history: current smoker. Review of physician progress note dated 4/13/26, indicated smoking status; current some days smoker. During an interview completed on 8/12/26, at 1:20 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E21 confirmed that the comprehensive assessment completed for Resident R16 on 5/5/26, was incorrectly coded no for smoking. Review of the admission record indicated Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's MDS dated [DATE], indicated diagnoses of Parkinson's disease (neurodegenerative disease, primarily of the central nervous system, affecting both motor and non-motor systems), neurocognitive disorder (acquired condition characterized by a decline in cognitive functions that interferes with daily life, ranging from mild impairment to severe dementia), and major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Section O0110 K1. Hospice - was marked with a check, indicating that the program was performed while a resident. Review of Resident R84's physician order recapitalization from January 2026, revealed an order on 1/2/26, to admit to hospice services with diagnosis of Parkinson's disease, discontinued 7/21/26. Further review of Resident R84's current physician order dated 7/21/26, indicated admit to hospice services with diagnosis of Parkinson's disease. Review of Resident R84's current plan of care indicated resident has a hospice care need due to terminal/end stage disease, initiated 1/2/26. Review of Resident R84's MDS dated [DATE], revealed Section O0110 K1. Hospice - was not marked with a check, indicating that the program was not performed while a resident. Interview on 8/12/26, at 2:10 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E20 confirmed Resident R84 receives hospice services and the MDS dated [DATE], did not include hospice and it was a data entry error. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of two residents (Resident R4, and R13). Findings include: Review of Registered Dietitian (RD) Job Description, indicated that it is the RD's duty to review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plans. The RD shall also assist in developing diet plans for individual residents based on the comprehensive assessment and care plan along with the residents' preferences and sated goals. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's clinical record revealed a Nutrition Evaluation dated 5/4/26, that indicated that resident required 1500-1800 milliliters (ml) of fluid per day, and that the plan is to continue with her current plan of care. Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to insert a peripheral IV (intravenous)- a short, flexible plastic tube placed into a small surface vein- usually in the hand or arm). Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile salt water solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/26, indicated diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident. During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. After the interview with the DON, a review of Resident R4's clinical record conducted on 8/13/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/25 12/30/25 1/27/26 2/24/26 3/31/26 4/28/26 5/26/26 6/30/26 Review of Resident R4's MDS dated [DATE], section V0200 question 14 indicated that dehydration was not triggered. Review of Resident R4's clinical record revealed a Certified Registered Nurse Practitioner (CRNP) progress note dated 11/20/25, that stated resident had a follow up appointment with cardiology (a doctor who specialized in the heart) and was evaluated regarding CHF (congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles),and was found to be euvolemic (having a normal volume of blood and body fluids) Secondly, she is identified as a patient with risk for dehydration and does have chronic hypohydration (a deficit in total body water below normal levels). Have offered IV fluids intermittently, historically she refuses IV placement. Infusion team (a specialized group of healthcare professionals who administer IV medications, and fluids) to follow up next week, and if agreeable would benefit from IV hydration and nutritional support. Also noted was that oral mucosa is moist (the soft, pink lining inside the mouth is properly hydrated). Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation (a brief physical exam that may indicate dehydration), and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 11/26/25. Review of Resident R4's MDS dated [DATE], Section K0520A indicated that resident received IV fluids while a resident. Review of Resident R4's clinical record revealed CRNP progress note dated 12/24/25, indicated She is identified as a patient with risk for dehydration and does have chronic hypohydration, and Infusion team to follow up next week, and if agreeable would benefit from IV hydration and nutritional support. Also noted was that oral mucosa is moist. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, nutritional evaluation, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 12/30/25. Review of Resident R4's clinical record revealed CRNP progress note dated 1/22/26, indicated She is identified as a patient with risk for dehydration and does have chronic hypohydration. Also noted was that oral mucosa is moist. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, nutritional evaluation, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 1/27/26. Review of Resident R4's MDS dated [DATE], Section K0520A indicated that resident received IV fluids while a resident Review of Resident R4's clinical record revealed CRNP progress note dated 2/18/26, indicated that she is identified as a patient with risk for dehydration and does have chronic hypohydration, and that oral mucosa is moist. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 2/24/26. Review of Resident R4's clinical record revealed CRNP progress note dated 3/18/26, indicated that she is identified as a patient with risk for dehydration and does have chronic hypohydration. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, nutritional evaluation, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 3/31/26. Review of Resident R4's MDS dated [DATE], Section K0520A indicated that resident received IV fluids while a resident. Review of Resident R4's clinical record revealed CRNP progress note dated 4/23/26, indicated that she is identified as a patient with risk for dehydration and does have chronic hypohydration, and that oral mucosa is moist. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 4/28/26. Review of Resident R4's MDS dated [DATE], Section K0520A indicated that resident received IV fluids while a resident. Review of Resident R4's clinical record revealed CRNP progress note dated 5/20/26, indicated that she is identified as a patient with risk for dehydration and does have chronic hypohydration, and that oral mucosa is moist. Review of Resident R4's clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 5/26/26. Review of Resident R4's clinical record revealed no related CRNP progress note, or nutrition note for June 2026, and clinical documentation, assessments, physician documentation, and nurse notes did not include a skin turgor evaluation, an order for laboratory blood screening related to dehydration, laboratory evaluation with a finding of dehydration risk, and provision of less intrusive interventions such as offering additional fluids. Review of Resident R4's clinical record revealed that she received IV fluids as ordered on 6/30/26. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13 clinical record revealed a Nutrition Evaluation dated 5/4/26, that resident required 1500-1800 ml of fluid a day, and that the plan is to continue with his plan of care. Review of Resident R13's clinical record revealed a physician order dated 7/29/26, to insert a peripheral IV insertion. Review of Resident R13 clinical record revealed a physician order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile saltwater solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R13 MDS dated [DATE], indicated a diagnosis of Non-Alzheimer Dementia (group of brain diseases that mainly affect the frontal and temporal lobes of the brain), Diabetes Mellites (when the body cannot use insulin correctly and sugar builds up in the blood) , and depression. Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident. During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. Review of Resident R13's clinical record conducted on 8/14/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/2512/30/2501/27/2602/24/2603/31/2604/28/2605/26/2606/30/2607/29/26 Review of Resident R13's clinical record Hydration Resident Risk Screening Tool , and dated 11/21/25, 12/24/25, 1/21/26, 2/18/26, 3/27/26, 4/24/26, 5/20/26, 6/25/26, and 7/23/26, failed to include skin turgor evaluation and provision of less intrusive interventions. Review of Resident R13's clinical record failed to include consent and education about the IV hydration program to Resident R13's Responsible Party. During an interview on 8/14/26, at 9:01 a.m. the DON stated that the IV hydration company has screening forms that are filled out by her and the CRNP every month, however they are not part of the clinical record. During an interview on 8/14/26, at 11:42 a.m. Registered Dietitian (RD) Employee E18 stated that she is aware of the Hydration Program when an outside vendor comes in at the end of every month to administer a one-time dose of IV fluids to residents found to be of hypohydration. The program start off with about four people, but some did not tolerate it. RD Employee E18 stated that she was not involved in determining who would benefit from this program. She did confirm as part of her routine Nutrition Assessments; she does estimate how much fluid a resident may require, and charts her findings accordingly. RD Employee E18 also confirmed that Resident R4 requires 1500-1800 ml of fluid per day, and that how much she drinks is recorded in her clinical record. Upon review of Resident R4' documented fluid intake for July 2026, RD Employee E18 confirmed that the resident appears to be meeting her estimated daily fluid needs as intake is often documented as 1400ml to greater than 2000 ml per day. RD Employee E18 stated that the meal trays provide approximately 1500 ml of fluid per day, and that additional fluids are provided by medication pass, water pitchers, left at bedside, and snacks. RD Employee E18 confirmed that she has not been asked to provide less invasive hydration programs, such as adding additional oral fluids. RD Employee E18 was asked if it is required to have blood work, or other physical assessments completed prior to administration of IV fluids to help determine the clinical need for IV fluids. RD Employee E18 stated no'. RD Employee E18 confirmed that most residents receive 500 ml of fluid for IV hydration, and that it provides approximately two-eight ounce glasses of fluid. State Agency asked if that amount of fluid provided one time per month would greatly increase a residents hydration status per month, to which RD Employee E18 replied no. During an interview on 8/14/26, at 12:46 p.m. CRNP Employee E19 stated that he was not involved with the decision to implement the IV hydration program, which began in November 2025, but that he is asked to evaluate the residents who receive it on a monthly basis. The IV hydration company has a list of criteria that they use to determine who will receive the IV hydration. CRNP Employee E19 confirmed that it is not required that traditional methods of assessing dehydration are implemented such as lab work, and that they [outside IV hydration company] are not treating dehydration, just if they are at risk for dehydration. CRNP Employee E19 stated that if he felt someone was dehydrated, he would order IV fluids and not wait for a scheduled monthly service. CRNP Employee E19 also agreed that 500 ml a month provided by the outside IV hydration company wouldn't help much. During interview on 8/14/26, at 1:14 p.m. information was disseminated to the DON that the facility failed to thoroughly evaluate and implement less intrusive interventions for residents identified as dehydration risk provided Intravenous hydration fluids for Residents R4, and R13, in accordance with professional standards of practice as required. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of four residents (Resident R95).Findings include: Review of facility policy Charting and Documentation, dated 12/22/26, indicated all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of the procedures and treatments will include care-specific details, including:The date and time the procedure/treatment was provided;The name and title of the individual(s) who provided the care;The assessment data and/or any unusual findings obtained during the procedure/treatment;How the resident tolerated the procedure/treatment;Whether the resident refused the procedure/treatment;Notification to family, physician or other staff, if indicated; and The signature and title of the individual documenting. Review of the clinical record indicated Resident R95 was admitted to the facility on [DATE]. Review of Resident R95's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/26, indicated diagnoses of chronic respiratory failure, chronic heart failure, and diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels). Review of facility provided document Wound Report, dated 8/5/26, revealed the Resident R95 has a stage 3 (full thickness wound that extends into the subcutaneous fat but does not expose muscle, tendon, or bone) pressure sore on his coccyx to the right inner buttock, with date of onset 4/1/26. Review of Resident R95's care plan dated 4/2/26, revealed a coccyx to the right inner buttock wound, with an intervention to administer treatment per physician order. Review of Resident R95's physician order dated 7/16/26, indicated wound care - coccyx to right inner buttock, cleanse with normal saline (sterile water), pat dry, apply betadine moistened gauze and cover with border gauze dressing BID (twice a day) and PRN (as needed); Notify wound care and MD (Medical Doctor)/CRNP (Certified Registered Nurse Practioner) of worsening every day and evening shift for wound care. Review of Resident R95's Treatment Administration Record (TAR) for July 2026, revealed the above treatment was not signed off as completed or refused on the following shifts: evening shift 7/20/26, and day shift 7/27/26. Review of Resident R95's TAR for August 2026, revealed the above treatment was not signed off as completed or refused on the following shifts: evening shift 8/1/26, and 8/5/26; and day shift 8/4/26, and 8/7/26. During an interview on 8/13/26, at 12:10 p.m., the Director of Nursing (DON) confirmed that Resident R95's TAR for coccyx wound treatment was incomplete on shifts/dates as identified above, confirming that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of four residents (Resident R95). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based upon review of facility policy, clinical records review, and staff interview, it was determined the facility failed to ensure a safe environment by failing to ensure that current smoking assessments were completed timely for two of two residents reviewed (Resident R16, and R76). Findings include: Review of facility's policy Smoking Policy- Residents dated 12/22/25, indicated that residents will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption; method of consumption; desire to quit smoking; ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation. The resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change, and as determined by staff. Review of admission record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/26, indicated the diagnosis of hypertension (high blood pressure), traumatic brain injury, and epilepsy (a neurological disorder associated with abnormal electrical activity in the brain marked by sudden episodes of sensory disturbance. loss of consciousness, or convulsions. Review of Resident R16's current care plan initiated 7/19/22, revealed: Safe Smoking: Educate family and visitors not to leave smoking materials in patient's room. Educate to interventions and Facility smoking policy and procedures. Secure smoking materials (cigarettes, matches, lighters, etc.) In medication room. Review of Smoking Safety assessment dated [DATE], indicated smoking history: current smoker. Review of physician progress note dated 4/13/26, indicated smoking status; current some days smoker. Review of physician progress note dated 7/23/26, revealed Smoking Cessation Counseling: no interest in cessation. During an interview completed on 8/12/26, at 1:40 p.m. the Nursing Home Administrator confirmed that the last smoking assessment for Resident R16 was completed on 7/15/25, and that the facility failed to re-evaluate Resident R16's ability to safely smoke. Review of the clinical record indicated Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's clinical record revealed an admission evaluation that stated resident smoke within the last year. Review of Resident R76's MDS dated [DATE], indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and muscle weakness. Review of Resident R76's clinical record revealed a progress note dated 4/1/26, that stated He is mobilizing more throughout the facility, also going outside to smoke. Review of Resident R76's clinical record revealed a progress note dated 4/14/26, that stated He does go outside to smoke multiple times per day and has no desire to quit smoking at this time. Review of Resident R76's clinical record revealed a progress note dated 7/14/26, that stated Writer was walking into work and seen resident sitting outside on back patio smoking a cigarette talking with another resident. Review of Resident R76's clinical record revealed a progress note dated 7/30/26, that stated resident was Going to smoke. Review of Resident R76's clinical record failed to reveal that a Smoking Safety assessment was completed until 7/30/26. During an interview on 8/13/26, at 12:16 p.m. the Director of Nursing (DON) confirmed that Resident R76 had been smoking at the facility since at least 4/1/26, and the facility failed to ensure that current smoking assessments were completed timely for Resident R76. 28 Pa. Code 201.18(c)(4) Management

Based on observation and staff interview, it was determined that the facility failed to ensure that current and accurate nursing staffing was placed in an accessible place for residents two of two nursing care units (1st floor and 2nd floor nursing care unit).Findings include:During an observation on 8/12/26, from 9:06 a.m. through 10:02 a.m. on both nursing care units (first and second floor) failed to include the accurate nursing staffing.During an interview on 8/12/26, at 1:29 p.m. Nursing home Administrator confirmed that the facility failed to have the accurate nursing staffing posted in a place that was accessible for residents for two of two nursing care units. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code : 201.18 (b)(3)Management.

Based on review of clinical records, and staff interviews, it was determined that the facility failed to maintain complete and accurate documentation for two of twelve residents (Resident R4, and R13). Findings include: Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to insert a peripheral IV (intravenous)- a short, flexible plastic tube placed into a small surface vein- usually in the hand or arm). Review of Resident R4's clinical record revealed a physician's order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile salt water solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/26, indicated diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section C0500 indicated a BIMS (Brief interview of mental status) score was 10, indicative of moderate cognitive impairment. Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident. During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. After the interview with the DON, a review of Resident R4's clinical record conducted on 8/13/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/25 12/30/25 1/27/26 2/24/26 3/31/26 4/28/26 5/26/26 6/30/26 Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's clinical record revealed a physician order dated 7/29/26, to insert a peripheral IV insertion. Review of Resident R13 clinical record revealed a Nutrition Evaluation dated 5/4/26, that resident required 1500-1800 ml of fluid a day, and that the plan is to continue with his plan of care. Review of Resident R13 clinical record revealed a physician order dated 7/29/26, to provide 500 ml of 0.9% normal saline (NA- a sterile saltwater solution), with various added vitamins, and minerals such as B vitamins, Vitamin C, Zinc, magnesium and calcium, one time only. Review of Resident R13 MDS dated [DATE], indicated a diagnosis of Non-Alzheimer Dementia (group of brain diseases that mainly affect the frontal and temporal lobes of the brain), Diabetes Mellites (when the body cannot use insulin correctly and sugar builds up in the blood), and depression. Section K0520A indicated that resident received intravenous (IV- fluids through the vein) while a resident During an interview on 8/13/26, at 11:51 a.m. the Director of Nursing (DON) stated that an outside company comes in every month to administer IV fluids to approximately 12 residents who were determined to be at risk for dehydration. Review of Resident R13's clinical record conducted on 8/14/26, revealed that resident had received the same orders for peripheral IV insertion and to administer 500 ml of 0.9% normal saline with added vitamins and minerals as 7/29/26, on the following dates: 11/26/25 12/30/25 01/27/26 02/24/26 03/31/26 04/28/26 05/26/26 06/30/26 07/29/26 During an interview on 8/14/26, at 9:01 a.m. the DON stated that the IV hydration company has screening forms that are filled out by her and the CRNP every month, however they are not part of the clinical record. The DON brought in paper copies of these forms and confirmed that the facility failed to maintain complete, and accurate documentation for two of twelve residents (Resident R4, and R13). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the failed to prevent cross contamination during a dressing change for one of three residents (Resident R12) facility failed to prevent cross contamination during a medication pass for one of three residents (Resident R21) and failed to implement enhanced barrier precautions for one of four residents (R32).Findings include: Review of the facility policy Dressings, Dry/Clean last reviewed 7/16/26, indicated the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure include but are not inclusive to: Clean the bedside stand. Establish a clean field. Place the clean equipment on the clean field. Discard used items into the designated container. Clean the bedside stand. Review of the facility's policy Administering Medications last reviewed 7/16/26, indicated medications are administered in a safe and timely manner. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, isolation precautions, etc.). Review of the facility Enhanced Barrier Precautions (EBP) last reviewed 7/16/26, indicated Enhanced barrier precautions are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use during high contact resident care activities. EPSs are indicated for residents with wounds and/or indwelling medical devices. EPB's target gown and glove usage during high contact resident care activities. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/26, indicated diagnoses of Alzheimer's disease (affects memory, thinking and behavior) anxiety and depression. Review of Resident R12's physician orders dated 8/5/26, indicated cleanse 2nd digit to left foot with normal saline solution, apply medical grade honey, calcium alginate and a border gauze dressing daily and as needed. During a dressing change observation completed on 8/11/26, at 9:18 a.m. Licensed Practical Nurse (LPN) Employee E3 was preparing to complete Resident R12's dressing change. After gathering supplies, LPN Employee E3 entered the room and placed items on the over the bed stand without establishing a clean field. After completion of the dressing change LPN Employee E3 failed to clean the over the bed stand. During an interview completed on 8/11/26, at 9:37 a.m. LPN Employee E3 confirmed not preparing a clean field on the over the bed stand prior to placing the dressing supplies and not cleaning the over the bed stand after completion of the dressing change and that the facility failed to prevent cross contamination during a dressing change Review of the clinical record revealed Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated diagnosis of heart failure (heart doesn't pump the way it should), diabetes (high sugar in the blood) and Cerebrovascular Accident (CVA- stroke caused by a blood clot blocking a brain vessel). Review of Resident R21's physician orders dated 8/11/26, indicated Lorazepam intensol oral concentrate 2 milligrams/milliliter (MG/ML) give 0.5 ML by mouth every 4 hours as needed for anxiety or agitation. Review of Resident R21's physician orders dated 8/11/26, indicated Morphine Sulfate oral solution 20 MG/ML give 0.25 ml by mouth every 2 hours as needed for pain or respiratory distress During a medication pass administration observation completed on 8/12/26, at 8:59 a.m. Licensed Practical Nurse (LPN) Employee E5 prepared Resident R21's medications. Upon drawing up the correct amount of the morphine sulfate into a syringe for administration placed the syringe directly onto the medication cart. Upon drawing up the correct amount of the Lorazepam Intensol into a syringe for administration placed the syringe directly onto the medication cart. LPN Employee E5 then picked up the syringes from the top of the cart for administration. During an interview completed on 8/12/26, at 9:31 a.m. LPN Employee E5 confirmed placing the medication syringes onto the medication cart and that the facility failed to prevent cross contamination during a medication administration pass. Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of anemia (low iron in the blood), diabetes (high sugar in the blood) and obstructive uropathy (blockage in the urine system that prevents urine from flowing) Review of Resident R32's physician orders dated 6/12/26, revealed 18 French foley catheter (insertion of a tube into the bladder to remove urine) with 10 cubic centimeter (cc) balloon to straight bag gravity drainage. The orders failed to reveal Enhanced Barrier Precautions (EBP) for the use of the foley catheter. During an observation completed on 8/11/26, at 10:58 a.m. Resident R32 was in bed a covered urinary drainage bag was hanging on his bedframe. During an interview completed on 8/12/26, at 1:00 p.m. the Infection Preventionist (IP) Employee E23 confirmed that Resident R32's physician orders failed to include EBP for the use of the foley catheter. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of clinical records, facility policies, and staff interviews, it was determined the facility failed to consistently implement and enforce its smoking policy for two of two residents who smoked (Resident 16, and R76). Findings include: Review of facility's policy Smoking Policy- Residents dated 12/22/25, indicated that residents will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption; method of consumption; desire to quit smoking; ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation. The resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change, and as determined by staff. Review of admission record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/26, indicated the diagnosis of hypertension (high blood pressure), traumatic brain injury, and epilepsy (a neurological disorder associated with abnormal electrical activity in the brain marked by sudden episodes of sensory disturbance. loss of consciousness, or convulsions. Review of Resident R16's current care plan initiated 7/19/22, revealed: Safe Smoking: Educate family and visitors not to leave smoking materials in patient's room. Educate to interventions and Facility smoking policy and procedures. Secure smoking materials (cigarettes, matches, lighters, etc.) In medication room. Review of Smoking Safety assessment dated [DATE], indicated smoking history: current smoker. Review of physician progress note dated 4/13/26, indicated smoking status; current some days smoker. Review of physician progress note dated 7/23/26, revealed Smoking Cessation Counseling: no interest in cessation. During an interview completed on 8/12/26, at 1:40 p.m. the Nursing Home Administrator confirmed that the last smoking assessment for Resident R16 was completed on 7/15/25, and that the facility failed to re-evaluate Resident R16's ability to safely smoke. Review of the clinical record indicated Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's clinical record revealed an admission evaluation that stated resident smoke within the last year. Review of Resident R76's MDS dated [DATE], indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and muscle weakness. Review of Resident R76's clinical record revealed a progress note dated 4/1/26, that stated He is mobilizing more throughout the facility, also going outside to smoke. Review of Resident R76's clinical record revealed a progress note dated 4/14/26, that stated He does go outside to smoke multiple times per day and has no desire to quit smoking at this time. Review of Resident R76's clinical record revealed a progress note dated 7/14/26, that stated Writer was walking into work and seen resident sitting outside on back patio smoking a cigarette talking with another resident. Review of Resident R76's clinical record revealed a progress note dated 7/30/26, that stated resident was Going to smoke. Review of Resident R76's clinical record failed to reveal that a Smoking Safety assessment was completed until 7/30/26. During an interview on 8/13/26, at 12:16 p.m. the Director of Nursing (DON) confirmed that Resident R76 had been smoking at the facility since at least 4/1/26, and the facility failed to ensure that current smoking assessments were completed timely for Resident R76. 28 Pa. Code 201.18(c)(4) Management

Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents with complete contact information for State Agency, Adult Protective Services, and Medicaid Fraud Control Unit in two of two nursing care units (first floor and second floor). Findings include:During a group interview on 8/12/26, at 11:15 a.m., residents indicated they were unaware of postings to contact other agencies to include the state agency, adult protective services, Medicaid fraud. Residents stated they definitely don't have those postings (department of health, adult protective services, Medicaid fraud) in and or around the nursing care units, and the group was unaware of how to contact any of those outside agencies. During an observation on 8/12/26, from 9:06 a.m. through 10:02 a.m., on both nursing care units (first and second floor) there was a variety of information posted for residents. This information failed to include (name, address, (mailing and email), and telephone numbers) all pertinent information: State Agency, Adult Protective Services, and Medicaid Fraud Control Unit.During an interview on 8/12/26, at 1:28 p.m. Nursing Home Administrator confirmed that the facility failed to have required postings in areas that are accessible to all residents with complete contact information for State Agency, Adult Protective Services, and Medicaid Fraud Control Unit, as required.28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(3) Management.

Based on review of facility policy, clinical records and staff interviews it was determined that the facility failed to provide assistance with Activities of Daily Living (ADL) involving consistent shower or baths for two out of six residents (Resident R2 and Resident R3).Findings include: Review of facility policy Activities of Daily Living (ADLs), Supporting dated 12/22/25, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the clinical record indicated Resident R2 was admitted to the facility 1/15/18. Review of Resident R2 Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/13/26, indicated diagnoses of chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), muscle weakness, and heart failure. Section GG - Functional Abilities, Question GG0130E indicated the resident was coded at a 01 for dependent helper does all of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R2's Kardex (documentation system that allows nurses to organize and reference key patient information essential for their care plans) revealed Resident R2's is scheduled to receive a bath/shower on Tuesday/Friday evening shift, requiring limited assistance. Review of Resident R2's care plan revealed a focus for ADL self-care deficit, updated 12/1/25, indicating Bathing: limited assistance. Review of Resident R2's documentation survey report for April of 2026, indicated that resident's shower days are scheduled on Tuesday and Fridays on the evening shift. Further review failed to include documentation to indicate Resident R2 received or refused a shower or bed bath on 4/3/26, 4/14/26, 4/17/26, 4/21/26, and 4/24/26. During an interview on 4/28/26, at 11:00 a.m., the Director of Nursing (DON) confirmed that Resident R2's shower documentation was incomplete and without documentation on 4/3/26, 4/14/26, 4/17/26, 4/21/26, and 4/24/26. Review of clinical record indicated Resident R3 was admitted to facility 1/12/24. Review of Resident R3's MDS dated [DATE], indicated diagnoses of cerebral infarction (stroke) affecting left side, anemia, and major depressive disorder. Section GG - Functional Abilities, Question GG0130E indicated the resident was coded at a 01 for dependent helper does all of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R3's Kardex revealed Resident R2's is scheduled to receive a bath/shower on Wednesday/Sunday evening shift, requiring total dependance. Review of Resident R3's care plan revealed a focus for self-care deficit, updated 1/12/24, indicating Bathing: total dependance. Review of Resident R3's documentation survey report for April of 2026, indicated that resident's shower days are scheduled on Wednesday and Sundays on the evening shift. Further review failed to include documentation to indicate Resident R2 received or refused a shower or bed bath on 4/8/26, 4/15/26, and 4/22/26. During an interview on 4/28/26, at 11:00 a.m., the DON confirmed that Resident R3's shower documentation was incomplete and without documentation on 4/8/26, 4/15/26, and 4/22/26. During an interview on 4/28/26, at 2:25 p.m., the Nursing Home Administrator (NHA) and DON that the facility failed to provide assistance with Activities of Daily Living (ADL) involving consistent shower or baths for two out of six residents (Resident R2 and Resident R3) as required. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy review, resident clinical records, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of five sampled residents (Residents R1, R4 and Resident R5). Findings include: The facility Wound care policy last reviewed 12/22/25, indicated that the information should be recorded in the resident's medical record includes the type of wound, date and time the wound care was given, any changes in the resident's condition, any problems or complaints made by the resident, and if the resident refused the treatment with the reason. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/8/25, indicated he had diagnoses that included spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure) and peripheral vascular disease (PVD: a progressive narrowing of the blood vessels impacting blood flow to the limbs). Review of Resident R1's care plans dated 10/2/25, indicated to administer treatments as per physician's order. Review of Resident R1's physician orders dated 10/3/25, indicated to cleanse coccyx with normal saline solution. Pat dry, apply collagen particle with silver and cover withborder gauze, every day-shift for wound care. Review of Resident R1's clinical progress notes dated 1/7/26, indicated his wound was assessed and found with the following description: Stage 4 wound to the coccyx, measuring 0.6cm x 0.5cm x 0.2 cm. Additional attempts to measure wound were refused by Resident R1. Review of Resident R1's February 2026 Treatment Administration Record (TAR) did not include treatments to Resident R1's wound on the following dates: 2/9/26, 2/17/26, and 2/25/26. Review of Resident R4's admission record indicated she was admitted [DATE]. Review of Resident R4's MDS assessment dated [DATE], indicated she had diagnoses that included diabetes, general weakness and hyperlipidemia. Review of Resident R4's care plans dated 11/12/25, indicated to administer treatments as per physician's order. Review of Resident R4's physician orders dated 2/14/26, indicated to cleanse coccyx wound with NSS (normal saline solution), pat dry, apply hydrofera-blue, cover with bordered gauze, every day-shift. Facility wound report indicated that Resident R4's wound was assessed on 3/5/26 and indicated the following description: Stage 3 pressure area to the coccyx, measuring 2.0 cm x 1.2cm x 1.0cm Review of Resident R4's February 2026 Treatment Administration Record (TAR) did not include treatments to Resident R4's wound on the following dates: 2/16/26, 2/20/26, 2/23/26, and 2/24/26. Review of Resident R5's admission record indicated he was originally admitted on [DATE], and readmitted [DATE]. Review of Resident R5's MDS assessment dated [DATE], indicated diabetes, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), morbid obesity, and hyperlipidemia (elevated lipid levels within the blood). Review of Resident R5's care plans dated 1/3/26, indicated to administer treatments as per physician's order. Review of Resident R5's physician order dated 2/5/26, indicated to cleanse wound to sacrum with NSS (normal saline solution). Apply collagen particles and cover with bordered dressing. Every day-shift for wound care. Facility wound report indicated that Resident R5 wound was assessed on 3/5/26, and indicated the following description: Stage 3 pressure area to the sacrum, measuring 0.2 cm x 0.2cm x 0.1cm Review of Resident R5's February 2026 Treatment Administration Record (TAR) did not include treatments to Resident R5's wound on the following dates: 2/22/26, 2/23/26 and 2/27/26 During an interview on 3/10/26, at 10:49 a.m. Licensed Practical Nurse (LPN) Employee E4 asked where else wound treatment and evidence of wounds treatments were documented and stated: treatments are on the TAR. Checked as completed. Unless I look at the area, there is no other way to know. During an interview on 3/10/26, at 11:02 a.m. Assistant Director of Nursing (ADON) Employee E1 was asked for proof of wound treatments for Residents R1, R4, and Resident R5. During an interview on 3/10/26, at 1:37 p.m. information was disseminated to the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) Employee E1 that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for Residents R1, R4, and Resident R5 as required. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to conduct surveillance mapping for five of 12 months (October 2024, February 2025, April 2025, August 2025, and September 2025), failed to timely implement isolation precautions during contact tracing testing for candida auris, failed to implement universal masking and droplet precautions throughout the facility timely for one of five residents (Residents R116), report newly identified cases within 24 hours during a COVID outbreak for four residents (Resident R50, R51, R54, and R91) and two staff members (Nurse Aide, Employee E16 and NA, Employee E24)and failed to prevent cross contamination during a medication pass for one of three resident's (Resident R91).Findings: Review of the facility's Surveillance for Infections last reviewed 7/11/25, stated the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on resident outcome and that may require transmission-based precautions and other preventative measures. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infections, the Infection Preventionist will collect data to help determine the effectiveness of such measures. Infections on an individual will be recorded daily to include detailed information and each month, information is collected and summarized. The data is analyzed to identify needs. Review of the Pennsylvania Department of Health Healthcare Facility Toolkit for Response to Candida auris (a fungus that can cause serious infections) dated May 2022, and updated June 2023, revealed C. auris can spread from one patient to another in hospitals and nursing homes. CDC recommends testing patients who may have come in contact with C. auris to see if they are carrying this fungus. This allows healthcare providers to know who is carrying the fungus and take steps to prevent it from spreading to other people. It was indicated residents require preemptive contact precautions while lab results are pending. The resident should be placed in private room, if possible. Healthcare personnel interacting with patients on Contact Precautions, or their environment, are required to wear a gown and gloves, donning their PPE upon room entry, and properly discarding before exiting (conventional capacity for PPE). Healthcare personnel should conduct diligent hand hygiene during and after contact with a C. auris positive patient or their environment; ensure alcohol-based hand rub is readily available. Disposable or dedicated patient-care equipment should be used whenever possible. Review of the facility's Coronavirus Disease (COVID-19) Testing Residents policy last reviewed 7/11/25, stated when testing residents with signs and symptoms of COVID, while test results are pending, symptomatic residents are placed on transmission-based precautions according to CDC guidance. The decision to discontinue empiric transmission based precautions for symptomatic residents can be made upon having negative results from at least one viral test. Symptomatic residents who refuse testing are placed on transmission-based precautions. Review of the facility policy Handwashing/Hand Hygiene last reviewed 7/11/25, indicated that the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: -Identify and Isolate First Case. -Identify Additional Cases and Exposures. -Exposed asymptomatic residents and HCP (health care professional) should be tested with a series of up to three viral tests. -Determine approach (contact-tracing, unit-based, facility-based). -Identify exposures because of close contact. -Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. -Evaluation and Monitoring of Residents It is important to assess for the following symptoms and implement prompt isolation and further evaluation for COVID: -Fever or chills -Cough -Shortness of breathe -Fatigue -Muscle or body aches -Headache -New loss of taste or smell -Sore throat -Congestion or runny nose -Nausea or vomiting -Diarrhea -Reporting Requirements Nursing Care Facilities must report information about staff and residents that test positive for COVID as needed, within 24 hours after being diagnosed to the Department of Health Review of the Center for Disease Control and Prevention (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes dated 9/11/25, stated when levels in the community are higher, consider having visitors and HCP wear a mask at all times in the facility and at a minimum, consider having residents wear a mask when outside of their room. Review of the facility's surveillance tracking and mapping from September 2024 to September 2025, failed to include the following: -October 2024 (Failed to include map) -February 2025 (Failed to include map) -April 2025 (Failed to include room [ROOM NUMBER] on map) -August 2025 (failed to include tracking for Candida Auris positive residents for Resident R45 and R59) -September 2025 (Failed to include map) Review of information submitted to the State Agency on 8/22/25, revealed the facility was notified on 8/15/25, a resident tested positive for Candida Auris. It was indicated further testing would be needed for all current residents on the first floor. Facility is following local DOH guidelines for containment, isolation, sanitizing, notification, and testing. Review of the facility's Candida auris testing log sheet revealed Resident R45 and R59 were tested for Candida auris on 8/27/25. Review of Resident R45's clinical record revealed enhanced barrier precautions were ordered on 9/3/25, for Multi-drug resistant organism colonization (MDRO), a total of eight days after preliminary testing occurred. The facility failed to timely implement isolation precautions for Resident R45. Review of Resident R59's clinical record revealed enhanced barrier precautions were ordered on 9/3/25, for Multi-drug resistant organism colonization (MDRO), a total of eight days after preliminary testing occurred. The facility failed to timely implement isolation precautions for Resident R59. During an interview on 9/24/25, at 12:22 p.m. the Director of Nursing (DON) stated Resident R45 and R59 should have been on the infection control tracking and mapping for August 2025. The DON confirmed Resident R45 and R59 were colonized with C. auris. During an interview on 9/26/25, at 10:55 a.m. information disseminated to DON that the facility failed to timely implement isolation precautions during preliminary testing for C. auris for Resident R45 and R59. Review of the facility's LTC Respiratory Surveillance Line List revealed Resident R116 began with symptoms on 8/18/25. The resident had a fever, cough, and chills. On 8/20/25, the resident was ordered a rapid test and the results were positive for COVID. Review of Resident R116's clinical record from 8/18/25, to 8/20/25, failed to include evidence droplet precautions were implemented for COVID-like symptoms. The facility failed to timely initiate droplet precautions for a resident with COVID-like symptoms. A further review of the facility's LTC Respiratory Surveillance Line List revealed the following: -Nurse Aide, Employee E16 tested positive for COVID on 8/22/25. -Nurse Aide, Employee E24 tested positive for COVID on 8/25/25. -Resident R54 tested positive for COVID on 8/26/25. -Resident R91 tested positive for COVID on 8/26/25. -Resident R50 tested positive for COVID on 8/28/25. -Resident R51 tested positive for COVID on 8/30/25. Review of information submitted to the State Agency from 8/22/25, to 8/31/25, failed to include evidence the facility reported newly identified cases of COVID within 24 hours as required for (NA, Employee E16, NA, Employee E24, Resident R50, R51, R54, and R91). During observations made on 9/22/25, through 9/24/25, facility staff and residents were not observed wearing source control throughout the facility during a COVID outbreak. During an interview on 9/24/25. at 12:24 p.m. the DON confirmed the facility failed to implement universal source control for residents and healthcare providers during a COVID outbreak. During an interview on 9/26/25, at 12:57 p.m. the Director of Nursing and Nursing Home Administrator were notified the facility failed to timely implement droplet precautions for Resident R116. The DON confirmed the facility failed to report newly identified positive COVID results within 24 hours. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/25, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and anxiety. During a medication pass observation for Resident R91 completed on 9/24/25, at 8:57 a.m. Licensed Practical Nurse (LPN) Employee E8 failed to complete hand hygiene prior to, during and after the medication pass as required. During an interview completed on 09/24/25, at 9:33 am. LPN Employee E8 confirmed not completing hand hygiene prior to, during and after the medication pass as required 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility documentation, clinical record, and staff interview it was determined that the facility failed to implement measures and plan of care, provide adequate supervision and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident with wandering behaviors and history of elopement behaviors. This enabled the resident to open a door which alarmed for 15 sec prior to unlocking and allowing access to an unsupervised stairwell which resulted in a fall down the stairs, resulting in an immediate jeopardy situation for one of three residents reviewed (Resident R1). Resident R1 sustained a head injury and was sent to a local hospital and then required further treatment at a Trauma Center of two staples for a laceration. Findings include: Review of facility policy Wandering and Elopements dated 2/10/23, indicated that The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. Elopement risk screenings will be completed on residents upon admission re-admission, quarterly, significant change in status, and as need. When a resident is identified to be at risk for elopement, this is will be care planned along with interventions identified to reduce the resident's risk for elopement. If a resident presents with increased unsuccessful elopement attempts or increased verbalizations to elope, the IDT team will re-evaluate the resident and current care plan. Resident R1 was admitted to the facility on [DATE], with the following diagnosis of chronic kidney disease, major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Alzheimer's disease (progressive disease that destroys memory) all of which remained current as of the MDS (minimum data set - a periodic assessment of resident needs) dated 2/10/23. Review of clinical documentation progress note nurses note dated 12/13/22, Resident R1 refused medications, extremely agitated, going from one exit to another and in unlocked offices. Review of facility provided documentation, dated 2/11/23, indicated the following: Resident R1 was propelling self in wheelchair around the unit, staff heard alarm sounding from the staircase exit door on South wing. When staff opened the door they observed Resident R1 at the bottom of the staircase landing. Review of clinical documentation progress notes nurses notes dated 2/11/23, indicated the following: Resident R1 was wandering up and down hallways for the duration of the morning shift looking for her parents and baby. Resident R1 approached the fire door and began pushing on it. The nurse heard the alarm and shouted for Resident R1 to stop. Resident R1 did not comply and continued pushing on door, which opened. Door slammed shut behind Resident R1 as Resident R1 entered the stairwell. Nurse opened door and observed Resident R1 at bottom of first flight of steps on landing - positioned on left side with left shoulder underneath as if in a kneeling position. Wheelchair was to the left behind the resident on the stairs. Resident R1 stated to staff I hurt and please get me up. Review of the elopement/wandering risk assessment dated [DATE], indicated that Resident R1 was not an elopement risk. Review of the facility investigation witness statements indicated the following: Employee E1: Resident R1 was going up and down hall. Resident R1 behavior of wondering up and down hall looking for room, Mom and Dad or way out. Employee E2: Resident R1 was roaming was roaming the halls since the beginning of the shift looking for a baby. Resident confused with dementia at baseline. Has a history of wandering up and down halls looking for husband, parents, etc. Employee E3: Resident R1 was rolling around the halls in wheelchair saying he/she needed to get home. Employee E4: Resident R1 came down hall in wheelchair looking for the babies and wanting to get out of here. Employee E5: Resident R1 was wheeling herself in her wheelchair. Resident R1 roams hallway at time's wants to go home. During a phone interview on 2/28/23 at 1:59 p.m. Resident R1 family member stated that Resident R1 is still able to read. During an interview on 3/1/23, at 12:46 p.m. Employee E1 indicated that Resident R1 wandered the hallways, on a frequent basis and Employee E1 stated that they would tell Resident R1 that if they touched the door (fire door) that the fireman would come, this would deter Resident R1. During an interview on 3/1/23, at 2:04 p.m. Employee E4 stated that Resident R1 was roaming the halls and asked for a way out saying that he/she needs to leave. During an interview on 3/1/23, at 1:03 p.m. Employee E5 indicated that Resident R1 liked to get in wheelchair shuffle through halls. During an interview on 3/2/23 at 2:05 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that Resident R1 was in the hallway and pressed the doorway to release the fire alarm on the doorway, wheeled self through doorway and went down the stairs in his/her wheelchair. During the interview the corporate consultant confirmed that the resident went through the fire door and down the stairs in his/her wheelchair. The facility refused to confirm that this behavior put Resident R1 at risk for elopement. The DON and NHA was made aware that an Immediate Jeopardy situation existed for residents on 3/2/23, at 2:05 p.m. and an immediate action plan was requested. On 3/2/23, at 2:07 p.m. the Immediate Jeopardy template was provided to the facility administration. On 3/2/23, at 10:37 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Resident R1 room was moved to the first floor. 2. Resident R1 had a trial with a wander guard for two weeks. 3. Facility purchased a baby doll for Resident R1. 4. Resident R1 was assessed for elopement risk on 2/14/23 and determined not to be an elopement risk by the facility. 5. All secured doors were immediately assessed by maintenance on 2/11/23, and the alarm company on 2/14/23. 6. Residents in the facility were assessed for elopement to include new admissions by 3/2/23. 7. Staff were educated prior to working by 3/3/23. 8. Audits for new admissions or change in condition of exhibiting exit seeking behaviors utilizing the elopement risk form and plan of care will be reviewed during morning clinical meeting for four weeks - with results reported to monthly QAPI. 9. Exit doors will be checked five times weekly by four weeks to ensure doors and alarms are functioning properly. During an observation on 3/2/23, at 9:50 p.m. (approximately), it was noted that a surveyor walking at a brisk pace from the nurses station to the fire door exit elapsed time (timed walk) was 31 seconds. During an interview on 3/3/23, at 10:47 a.m. Nurse Aide (NA) Employee E10 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 10:49 a.m. NA Employee E11 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 10:53 a.m. Registered Nurse Employee E12 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 10:55 a.m. Registered Nurse Employee E13 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 10:56 a.m. Housekeeper Employee E14 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 10:58 a.m. Licensed Practical Nurse Employee E15 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 11:00 a.m. NA Employee E16 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 11:03 a.m. NA Employee E17 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement. During an interview on 3/3/23, at 11:09 a.m. LPN Employee E18 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. During an interview on 3/3/23, at 11:11 a.m. NA Employee E19 confirmed that they received education on behavior assessment intervention and monitoring to include implementing measures, and plan of care provide adequate safety measures prevent elopement. Wandering and Elopement and verbalized the education back during the interview. The review of the documentation received from the facility on 3/3/23, at 1:04 p.m. revealed all elements of the Corrective Action Plan were substantially completed per the facility's action plan. Verification of the facility's plan was completed, and the Immediate Jeopardy was lifted on March 3, 2023, at 1:22 p.m. 483.25 (d)(1)(2) Free of Accidents Hazards/Supervision Devices. 28 Pa. Code 201.18 e (1)(3) Management 28 Pa. Code 207.2(a) Administrators Responsibility 28 Pa. Code 211.12 (a)c (d)(3)(5) Nursing services.

Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to prevent new pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of a pressure ulcer for one of one residents (Resident R99). Findings include: A review of the facility policy Initial Care Plan Completion and Ongoing Care Plan Updates dated 7/8/21, indicated the facility will follow a uniform process for initiating the care plan upon admission and ensure that care plans are updated. Staff will update the care plans related to the physician orders and/or changes in care needs. A review of the clinical record indicated Resident R99 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nurse progress note dated 9/16/21, indicated brace (immobilizer) intact on left leg. A review of a hospital plan of care discharge document dated 9/16/21, indicated Resident R99 was to remain in the immobilizer and discharge to rehabilitation services. A review of the Braden Scale for Predicting Pressure Ulcer Risk dated 9/30/21, indicated that Resident R99 was at risk for the development of pressure ulcers. During an interview on 10/15/21, at 2:00 p.m., The Assistant Director of Nursing (ADON) Employee E4 revealed that Resident R99 wore the left knee immobilizer daily. A review of Resident R99's Interdisciplinary Care Plan initiated 9/16/21, did not include the risk of pressure ulcer development due to the presence of the left knee immobilizer. A review of a physical therapy (PT) progress note dated 10/1/21, indicated Resident R99 reported discomfort with the top of the knee immobilizer rubbing against the skin. PT performed a skin inspection and noticed a wound approximately 6 x 2.5 cm (centimeters) of the left knee. A review of an orthopedic office note dated 10/5/21, indicated Resident R99 had been in the immobilizer in the nursing home and has a near full-thickness (damage that extends to all layers of the skin) area to the posterior (back) of the knee and discontinue the knee immobilizer. There was no evidence in the clinical record that the knee immobilizer was assessed by nursing from 9/16/21 through 10/5/21. During an interview on 10/15/21, at 2:00 p.m., Assistant Director of Nursing (ADON) Employee E4 confirmed that the Plan of Care initiated on 9/16/21, did not include risk of pressure ulcer development due to the presence of a left knee immobilizer which resulted in harm in the development of a pressure ulcer for Resident R99. 28 Pa Code: 211.11(a)(b)(c)(d) Resident care plan.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to timely provide adequate preventative treatment and services to prevent new pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of a pressure ulcer for one of four residents (Resident R99) reviewed. Findings include: A review of the facility policy Prevention of Pressure Ulcers/Injuries dated 7/8/21, indicated residents will be assessed for risk factors weekly to include areas of impaired circulation due to pressure from positioning or medical devices. The skin should be inspected on a daily basis when performing or assisting with personal care or ADL's (activities of daily living). A review of the clinical record indicated Resident R99 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS-periodic assessment of care needs) dated 9/23/21, indicated that Resident R99 required extensive assistance of two staff for bed mobility and was at risk for pressure ulcer development but had no pressure ulcers at that time. A review of the Braden Scale for Predicting Pressure Ulcer Risk dated 9/30/21, indicated that Resident R99 was at risk for the development of pressure ulcers. A review of a nurse progress note dated 9/16/21, indicated brace intact on left leg. A review of the Admission Evaluation dated 9/16/21, indicated left knee with [CONDITION(S)] (swelling) and did not include the knee immobilizer in place. A review of the facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Interdisciplinary Care Plan did not include evidence that Resident R99's Care Plan included the risk of pressure ulcer development due to the presence of the left knee immobilizer on 9/16/21. During an interview on 10/15/21, at 2:00 p.m., Assistant Director of Nursing (ADON) Employee E4 confirmed that the Plan of Care did not include the risk of pressure ulcer development due to the presence of the left knee immobilizer on 9/16/21. A review of hospital plan of care discharge documents dated 9/16/21, indicated Resident R99 was to remain in the immobilizer and discharge to rehabilitation services. A review of the physican orders dated 9/16/21 through 10/1/21, did not include treatment to the left knee, or application of the left knee immobilizer. A review of the weekly body audits dated 9/16/21 though 10/1/21, indicated skin intact and did not include that the left knee immobilizer was in place or assessed. A review of a physical therapy (PT) progress note dated 10/1/21, indicated resident R99 reported discomfort with the top of the knee immobilizer rubbing against the skin. PT performed a skin inspection and noticed a wound approximately 6 x 2.5 cm (centimeters) of the left knee. Nursing was notified. There was no evidence in the clinical record that nursing assessed the wound to the left knee on 10/1/21, or that the care plan was updated to include this wound. A review of a physician order dated 10/1/21, indicated [MEDICATION(S)] cream 1% (an anti-infective) apply to left posterior (behind) knee topically every evening shift for wound care. A review of the treatment administration record (TAR) indicated the above treatment was applied 10/1 through 10/14/21. During an interview on 10/15/21, at 2:00 p.m., The ADON Employee E4 revealed that Resident R99 wore the left knee immobilizer daily. A review of an orthopedic office note dated 10/5/21, indicated Resident R99 had been in the immobilizer in the nursing home and has a near full-thickness (damage that extends to all layers of the skin) area to the posterior (back) of the knee and discontinue the knee immobilizer. There was no evidence in the clinical record that the knee immobilizer was assessed by nursing from 9/16/21 through 10/5/21. A review of a physician wound note dated 10/7/21, indicated Resident R99 had an unstageable pressure injury (USPI) measuring 2.2 x 1.8 cm from a left leg medical device immobilizer. A review of a physician wound note dated 10/14/21, indicated Resident R99 had a medical device associated USPI left leg from immobilizer measuring 2.2 x 1.9 cm and required sharp excisional debridement (removal of dead tissue) with a scalpel (surgical knife) to the level of subcutaneous (fat tissue under the skin). During an interview on 10/15/21, at 2:00 p.m., ADON Employee E4 confirmed that Resident R99 was admitted to the facility with a left tibial fracture on 9/16/21, which necessitated placement of a left knee immobilizer brace and had then developed an USPI to the left posterior knee on 10/1/21, which was due to pressure from the left knee immobilizer brace. ADON Employee E4 confirmed that Resident R99 had not been reassessed for risk of pressure ulcer development after placement of the immobilizer brace and that there were no interventions to prevent pressure on the left knee area implemented until the pressure area developed on 10/1/21. The facility staff failed to assess and implement measures to prevent pressure ulcer development associated with pressure from a left knee brace resulting in harm to Resident R99. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/24/21. 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, an incident report and staff interview, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury. The incident resulted in actual harm to the resident who sustained a laceration to the forehead requiring transfer to the hospital for sutures to one of 15 residents reviewed (Resident R1). Findings include: The facility's Abuse and Neglect policy, dated 4/28/16, indicated that neglect means the failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. The facility's Fall Prevention Is Everyone's Responsibility policy, dated 4/28/16, indicated to use footrests, and to push, don't pull wheelchairs except in shower rooms where the transition is sloped at the entrance/exit. The Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 6/11/16, indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the information dated 1/8/17, submitted by the facility regarding an incident that occurred on 1/7/17, at 9:25 p.m. revealed that Nurse Aide (NA), Employee E1, transported Resident R1 out of the shower room, with the resident facing forward, and not sitting all the way back in the wheelchair. The wheelchair did not have leg rests on at the time of the event as per the facility transportation policy dated 4/28/16. The facility indicated that Employee E1 was trained regarding the facility transportation policy during general orientation. Upon exiting the shower room, there was a slight decline/slope transition into the hallway. While going down this decline/slope, Resident R1 fell forward onto the floor hitting his/her head sustaining a laceration to the forehead. The incident required transfer to the hospital for repair of the forehead laceration with twenty-two sutures. At the time of the incident, Employee E1 was re-educated by the nurse regarding entering and exiting shower rooms and the facility nursing staff were inserviced by the Director of Nursing on process of entering and exiting the shower rooms. During an interview on 1/24/17, at 1:35 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that Employee E1 failed to provide safe transport that resulted in actual harm to Resident R1 when he/she fell out of the wheelchair and sustained a laceration. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/6/16, 8/28/15. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/16/16. 28 Pa.Code 201.29(a)(c)(d) Resident rights. 28 Pa.Code 211.10(d) Resident care policies. Previously cited 11/28/16, 1/6/16, 8/28/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/28/16, 9/16/16, 8/28/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/16/16, 1/6/16, 8/28/15.

Based on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to obtain prompt treatment for [REDACTED]. Findings include: The Nursing Policy "Pressure Ulcer Prevention and Treatment" last reviewed on 1/28/12, indicated to assess all residents skin on admission/re-admission using a Admission Skin Assessment, including a treatment plan of care. the facility will assure changes are recognized, evaluated and reported to the physician. The closed clinical record indicated Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment of the resident's care needs) dated 5/7/12, through 8/4/12, indicated Resident CR1's skin was intact without current or previous pressure sores. Following a two day stay in the hospital on [DATE], the hospital discharge transition summary on 7/28/12, identified a Stage I (the beginning of skin breakdown with intact skin and non blanchable redness) pink pressure ulcer developed on the resident's coccyx (tailbone). The note indicated that skin lubricants including [MEDICATION NAME] and Sensicare were applied to the site and required frequent positioning. On re-admission on 7/28/12, at 5:45 p.m., the Stage I pressure area was not identified on admission and there was no physician order for [REDACTED]. Review of the facility's Incident/Accident Report for Resident CR1 dated 8/6/12, indicated during morning (AM) care, the area on the coccyx was at first identified as a closed deep tissue injury and a review of Resident R1's Skin Grid dated 8/6/12, indicated that it was a Stage II Pressure Ulcer (wound with partial thickness loss of skin layers) measuring 7.1 centimeters (cm) by 5 cm in width drainage. There was no Care Plan in place for Resident CR1 from 8/6/12 through 9/16/12, to assess skin integrity and to determine the resident's care, goals and interventions. A physician order dated 8/6/12, indicated to apply Replicare (an [MEDICATION NAME]-absorb bacterial contamination) and apply every two days to Resident CR1's pressure sore to the coccyx. During a review of Resident CR1's physician progress notes [REDACTED]. During a review of Resident CR1's physician progress notes [REDACTED]. black necrotic wound with infection. During an interview on 10/11/12, at 10:20 a.m., Licensed Practical Nurse (LPN) Employee E2, confirmed there was no assessment, physician order or documentation to reflect timely treatment of [REDACTED]. During an interview on 10/11/12, at 11:00 a.m., the Director of Nursing confirmed that there was no care plan in place for impaired skin integrity with interventions for Resident CR1 and that the physician progress notes [REDACTED]. 28 Pa. Code: 211.2(a)(d)(1)(2) Physician services. 28 Pa. Code: 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.