Every finding on record at Bridgeville Rehabilitation & Care Center

Based on review of facility policy, facility documentation, observations, and staff interviews, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for six of 12 months (January 2026, February 2026, March 2026, April 2026, May 2026, June 2026).Findings include:Review of facility policy Infection Control Outcome and Process Surveillance and Reporting last reviewed 3/20/26, indicated the Infection Preventionist will conduct regular Outcome Surveillance which consists of collecting and documenting data on individual cases and comparing the collective data standard, written definitions of infection. Process Surveillance will be used to review practices directly related to patient care such as proper hand hygiene, use of disposable gloves, and observation of the environment. These methods will detect possible communicable diseases or infections, plan control activities before communicable diseases or infections can spread to others and identify and manage potential outbreaks of disease. They will also be used to identify whether the practices comply with established prevention and control procedures and policies based on recognized standards.Review of the facility's Infection Control documentation for the previous six months (January 2026-June 2026) failed to reveal surveillance for tracking infections for residents in four of six months (January 2026, February 2026, March 2026 and April 2026), and the previous six months (July 2025 -December 2025) were not available for review.During an interview on 7/16/26, at 11:00 a.m. Infection Preventionist (IP) Employee E4 confirmed that the facility failed to accurately track communicable diseases and infections.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on clinical records, medication regimen reviews, and staff interviews, it was determined that the facility failed to ensure the attending physician documented that they reviewed the pharmacy recommendation or irregularities in a timely manner for four of five residents reviewed (Resident R6, R7, R11, and R101).Findings include: Review of facility policy Medication Regimen Review reviewed 3/20/26, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist. The Medication Regimen Review (MRR) includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. It looks for irregularities like ensuring a written diagnosis, indication, or documented objective findings to support each medication. Recommendations are acted upon and documented by the staff and/or the prescriber. Review of the clinical record revealed Resident R6 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease (gradual loss of memory and cognitive abilities, eventually leading to inability to perform simple tasks), dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 6/23/26, indicated the diagnoses remain current. Review of the Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) for 10/14/25, 11/5/25, 12/8/25, 2/28/26, 6/17/26, and 7/15/26, failed to indicate Resident R6's physician reviewed and signed the pharmacy recommendations. The facility was unable to provide documentation for pharmacy recommendations dated 12/8/25 and 4/29/26. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease, dementia, and diabetes. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of the Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) for 9/6/25, 11/5/26, 2/28/26, 3/31/26, and 5/27/26, failed to indicate Resident R6's physician reviewed and signed the pharmacy recommendations. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], with the diagnoses that included dementia, depression, and history of falling. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of the Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) for 10/17/25, 12/8/25, 1/23/26, and 6/17/26 failed to indicate Resident R6's physician reviewed and signed the pharmacy recommendations. Review of the clinical record indicated Resident R101 was admitted to the facility on [DATE], with diagnoses that included dementia, high blood pressure, and insomnia. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of the Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) for 4/30/26, 5/30/26, and 6/17/26, failed to indicate Resident R6's physician reviewed and signed the pharmacy recommendations. The facility was unable to provide documentation for pharmacy recommendations dated 10/17/25, and 7/15/26. During an interview on 7/16/26, at 10:00 a.m. the Director of Nursing confirmed the facility could not locate all the past pharmacy recommendations, and confirmed the facility failed to obtain the residents physician's signature for the above dates.28 Pa Code201.14(a)Responsibility of Licensee28 Pa Code.211.9(k)Pharmacy Services

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents reviewed (Residents R5 and R164).Findings include: Review of the facility policy Dialysis; Hemodialysis (HD) - Communication and Documentation dated 3/20/26. The policy indicates, prior to the patient leaving the center for HD, a licensed nurse will complete the Hemodialysis Communication Record (pre/post dialysis evaluation) and send with the patient to the HD facility. Following completion of the HD, the dialysis facility should complete and return the form to the center with the patient. Upon return of the patient to the center, a licensed nurse will: review the dialysis facility communication; evaluate/observe the patient; and complete the post-hemodialysis treatment evaluation using the Hemodialysis Communication Record (pre /post dialysis evaluation). Review of the clinical record indicated Resident R5 was originally admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS-a periodic assessment of care needs) dated 7/3/26, indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R5's physician order dated 3/12/26, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Transport time scheduled for 11:00 a.m. Review of Resident R5's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center]. Resident R5's dialysis communication forms from 5/13/26 through 7/13/26 revealed incomplete communication on the following dates:Pre dialysis information incomplete: Incomplete assessment on the dialysis log prior to departure to dialysis center (to be completed by nursing facility nurse) on the following date;6/29/26. Dialysis information center information incomplete Incomplete assessment to be completed by dialysis center on the dialysis log on the following dates;6/3, 7/3. Post dialysis information incomplete Incomplete assessment on dialysis log upon return to the facility (to be completed by nursing facility nurse) on the following dates; 5/13, 5/18, 5/20, 5/22, 5/25, 5/27, 6/1, 6/3. 6/12, 6/15, 6/17, 6/19, 6/22, 6/24, 6/26, 7/10. Review of the clinical record indicated Resident R164 was admitted to the facility on [DATE]. Review of Resident R164's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R164's physician order dated 3/12/26, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Transport time scheduled for 10:15 a.m. Review of Resident R164's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center]. Resident R164's dialysis communication forms from 5/13/26 through 7/13/26, failed to reveal dialysis communication sheets present for 5/13/26, 5/20/26, 5/27/26, 6/10/26, 6/17/26, 6/24/26, and 7/1/26. Review of facility census information confirmed Resident R164 was present in the facility on the above dates. Review of Resident R164's progress notes failed to reveal documentation of dialysis refusals for the above dates or other documentation relating to dialysis for the above dates. During an interview on 7/15/26, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained for two of three residents. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to maintain nutritional status for three of nine residents reviewed for nutritional concerns (Resident R39, R81, and R164).Findings include: The facility policy Weights and Heights dated 3/20/26, indicated, Based on the patient's comprehensive assessment, the Center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the patient's clinical condition demonstrates that it is not possible for the patient's preferences to indicate otherwise. The facility policy Nutritional Management dated 3/20/26, indicated, Patients within the Center will maintain adequate parameters of nutritional status, to the extent possible, to ensure each patient is able to maintain the highest practicable level of well being. Staff will provide nutritional care and services to each patient, consistent with the patient's comprehensive assessment and will provide a therapeutic diet that accounts for the patient's clinical condition and preferences. Review of the clinical record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/4/26, included diagnoses of chronic kidney disease (gradual loss of kidney function), high blood pressure, and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a physician's order dated 12/15/25, indicated for staff to weigh every Monday for four weeks, then monthly thereafter. Review of Resident R39's plan of care for initiated 12/9/25, indicated for staff to weigh Resident R39 as ordered and alert dietician and physician to any significant loss or gain. Review of Resident R39's weight record indicated on 5/6/26, Resident R39 was weighed twice, 340 pounds and 353 pounds three hours later. No additional weights assessments were completed to verify accuracy. The next weight assessment was on 6/10/26, for 354.4 pounds. Review of a progress note dated 6/1/26, indicated Resident R39 had increased edema. Review of a weight change note dated 6/12/26, at 8:34 a.m. indicated a Resident R39 triggered for a significant weight gain. Review of a physiatry progress note dated 6/16/26, at 8:53 indicated that Resident R39 had scrotal edema. Review of a progress note dated 6/18/26, at 2:00 a.m. indicated Resident R39 was transferred to the hospital due to severe swelling and pain to scrotum. Review of a progress note dated 6/18/26, indicated Resident R39 was admitted to the hospital for a diagnosis of congestive heart failure. Review of a progress note dated 6/15/26, at 1:32 p.m. indicated Resident R39 had visible edema to penis and scrotum with increased pain. Review of a hospital emergency room note dated 6/18/26, indicated Resident R39 had scrotal edema and shortness of breath that has been progressing over the past few days. Review of hospital discharge paperwork dated 7/2/26, indicated that Resident R39 received aggressive diuresis (increased urine production) while hospitalized . Review of facility census information indicated Resident R39 was readmitted on [DATE]. Review of Resident R39's weight record indicated a readmission weight on 7/3/26, of 325.5 pounds. Review of the clinical record indicated that Resident R81 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and the presence of a stage four pressure ulcer (full-thickness skin and tissue loss). Review of a physician's order dated 6/15/26, indicated that Resident R81 is to receive 30 ml (milliliters) of liquid protein twice daily for wound healing. Review of Resident R81's plan of care for risk for skin breakdown initiated 6/14/26, included the intervention of, provide supplements as ordered. Review of a progress note dated 6/18/26, at 7:35 p.m. indicated Resident R81 was transferred to the hospital for stomach pain. Review of the physician's orders indicated that all Resident R81's medications were discontinued on 6/19/26, and again reordered upon his return later that day. Review of the physician's orders indicated that Resident R81's liquid protein was not reordered. During an interview on 7/14/26, at approximately 12:45 p.m. Resident R81 stated that he has not been receiving his supplement. Review of the clinical record indicated Resident R164 was admitted to the facility on [DATE]. Review of Resident R164's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of a physician's order dated 1/16/26, discontinued 7/7/26, indicated that Resident R164 is to receive 120 ml of liquid nutritional supplement twice daily. Review of a physician's order dated 2/23/26, discontinued 7/7/26, indicated that Resident R164 is to receive fortified pudding twice daily to promote weight maintenance. Review of a diet order dated 2/5/26, discontinued 7/7/26, indicated Resident R164 received a regular texture, thin liquid consistency diet. Review of a progress note dated 7/6/26, at 10:20 a.m. indicated Resident R164 was transferred to the hospital. Review of a progress note dated 7/7/26, at 1:21 p.m. indicated, resident still in ER (emergency room) at [local hospital], still having testing completed. did see ST (speech therapy) and was downgraded to puree diet with honey thick liquid related to coughing while eating. Review of a progress note dated 7/9/26, at 10:43 p.m. indicated Resident R164 returned to the facility with no medication changes. Review of facility census information indicated Resident R164 was present in the facility from 7/9/26, through 7/14/26, when he was re-hospitalized until 7/16/26. Review of Resident R164's diet orders failed to include a diet order active from 7/7/26, through 7/16/26. Review of the diet order dated 7/16/26, indicated Resident R164 received a renal diet, regular texture, thin liquid consistency. Review of Resident R164's clinical record failed to include reassessment by Speech Therapy upon readmission to the facility to ensure the resident is able to have a regular texture, thin liquid diet after being ordered puree diet with honey thick liquid at the hospital. During an interview on 7/16/26, at approximately 11:30 the Regional Dietary Manager Employee E25 confirmed that when a resident is readmitted , the meal tracker system automatically reactivates the previous diet. If any changes are needed, nursing staff need to enter a new diet order. Further review of the physician's orders failed to include orders for the fortified pudding or the liquid nutritional supplement. During an interview on 7/16/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement interventions to maintain nutritional status for one of three residents reviewed for nutritional concerns for three of nine residents. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.6 (b) Dietary services.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing

Based on a review of facility policy and records and staff interviews, it was determined that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 19 of 42 licensed nurses (Licensed Practical Nurse (LPN) Employees E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, E16, and E17, and Registered Nurse (RN) Employees E18, E19, E20, E21, E22, and E23).Review of the facility policy, Cardiopulmonary Resuscitation (CPR) dated ===, previously dated ===, indicated Licensed nursing staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. Online-only certification is not acceptable.On [DATE], the Nursing Home Administrator (NHA) provided a list of 24 currently employed LPNs and 18 currently employed RNs.On [DATE], at approximately 2:00 p.m. the NHA provided copies of the facility's licensed nurse's CPR certification cards. CPR certification cards were not available for review for LPN Employees E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, E16, and E17, and RN Employees E18, E19, E20, E21, E22, and E23.During an interview on [DATE], at approximately 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR 19 of 42 licensed nurses. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for six of sixteen residents (Resident R9, R13, R16, R81, R99, and R131).Findings include: Review of facility policy Activities of Daily Living (ADL) reviewed 3/20/26, indicated the center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/26, indicated diagnoses of non-Alzheimer's dementia (dementia caused by vascular, Lewy body or frontotemporal dementia), hypertension (high blood pressure), and anemia (lack of healthy red blood cells, leading to insufficient oxygen delivery to the body's tissues), a BIMS of 14. Section GG 130 personal hygiene indicates resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). During an interview on 7/14/26, at approximately 9:30 a.m. Resident R9 was observed with unkept fingernails on both hands, with debris under and on the sides of each fingernail of the resident's left hand. When asked, the resident stated she would like to have her nails cleaned and trimmed, she stated yes, they are a bit long and need cleaned. During rounds on 7/14/26 at approximately 11:30 a.m. with Licensed Practical Nurse (LPN) Employee E1 and Resident R9, LPN Employee E1 confirmed the unkept fingernails on both hands, with debris under and on the sides of each fingernail of the resident's left hand. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated diagnoses of Parkinson's disease (brain disorder that affects movement), schizophrenia (serious mental health condition affects thinking, feelings, and behavior), and anxiety, a BIMS is not scored Section C 100 cognitive patterns indicates resident is rarely/never understood. Section GG 130 personal hygiene indicates resident requires setup or clean up assistance (helper sets up or cleans up). During an interview on 7/14/26, at approximately 10:30 a.m. Resident R16 was observed with unkept fingernails on both hands. When asked if he thought his fingernails needed trimmed, the resident just looked at his fingernails and did not respond. During rounds on 7/14/26, at approximately 11:30 a.m. with LPN Employee E1 and Resident R16, LPN Employee E1 confirmed the unkept fingernails on both hands. LPN Employee E1 described Resident R16's fingernails as very long, thick and dirty. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), a duodenal ulcer (an open sore in the upper small intestine), and muscle wasting, and a BIMS score of 12. Section GG: Functional Abilities indicated Resident R13 required partial/moderate assistance with upper-body dressing and substantial/maximal assistance with lower-body dressing. During an interview and observation on 7/14/26, at approximately 12:30 p.m. Resident R13 was noted to still be in his gown in bed. He had long fingernails, hair, and beard. When asked, Resident R13 stated he wanted a hair cut and to be clean-shaven. Review of the clinical record indicated Resident R131 was admitted to the facility on [DATE]. Review of Resident R131's MDS dated [DATE], indicated diagnoses of Parkinson's disease, coronary artery disease (damage or disease in the heart's major blood vessels), and muscle weakness, and a BIMS score of 15. During an interview and observation on 7/14/26, at approximately 12:40 p.m. Resident R13's bed linen was noted to have brown matter smeared on it. Review of the clinical record indicated Resident R81 was admitted to the facility on [DATE]. Review of Resident R81's MDS dated [DATE], indicated diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic pain syndrome, and a BIMS score of 15. During an interview on 7/14/26, at approximately 12:45 p.m. Resident R81 stated that call light response on night shift is poor. During an interview on 7/15/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided. 28 Pa. Code: 211.12(1) Nursing services.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that residents were treated in a manner that promotes his/her quality of life and to facilitate resident self-determination through support of resident choice, for fifteen of thirty-two (Resident R3, R4, R5, R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, and R511). Residents R500-R511 represent a request for confidentially with the interview. Findings include: Review of the Resident Rights policy last reviewed 3/20/26, indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The resident has the right to exercise their rights as a resident of the community and as citizen. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: The resident has a right to choose activities, schedules, health care and providers of health care services consistent with his/her interests, assessments, plan of care and other applicable provisions. The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident Council Minutes dated 5/27/26, indicated residents requested to be able to go outside at the facility. During a group interview, on 7/13/26 at approximately 1:30 p.m., when asking the residents if they had any concerns, the group consensus was, they would like to be able to go outside. Resident's comments: you can only go outside and sit when your family visits and takes you out. If you don't have any family or your family can't visit often you just don't get to go out. Residents stated they have asked multiple times to get this addressed and nothing happens and we are halfway through summer. Review of Resident R3's clinical record indicated admission to the facility on 8/5/22. Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/6/26, indicated the diagnoses of cerebral palsy (a neurological disorder that affect body movement and muscle coordination, often caused by abnormal brain development or damage to the developing brain), hypertension (high blood pressure), and diabetes (body does not use insulin effectively) a BIMS of 15. During an interview with Resident R3 on 7/14/26 at approximately 12:05 p.m., the resident expressed concerns over not being permitted to go outside at the facility. She stated, the facility makes it so the smokers can go outside. I understand they want to keep everyone safe, but can't they figure something out anything? I would just like to be able to have some time outside, can you please make them do something? Please fix this for me. Review of Resident R3's care plan dated 8/8/22 indicated encourage and facilitate R3's activity preferences include all but especially bingo, arts and crafts, pop and country music, sitting/relaxing outside. Review of Resident R4's clinical record indicated admission to the facility on 8/18/25. Review of Resident R4's MDS dated [DATE], indicated diagnoses of heart failure (heart muscle is unable to pump enoughblood to meet the body's need for blood and oxygen), hypertension (high blood pressure), and diabetes (body does not use insulin effectively) a BIMS of 15. During an interview with Resident R4 on 7/14/26 at approximately 1:00 p.m., the resident expressed concerns over not being permitted to go outside at the facility. She stated, the only time I get to go outside is when my son or daughter come to visit, they work and have family to take care of. Why can't they let us outside for some fresh air, sunlight, and see the plants? I feel bad for those people who don't have family and can't go outside at all. Review of Resident R4's care plan dated 8/27/25 indicated it's important for R4 to go outside when the weather is good and enjoy eating/drinking, sitting, talking to visitors. Review of the clinical record indicated Resident R5 was originally admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids) a BIMS of 15. During an interview with Resident R5 on 7/15/25 at approximately 9:00 a.m., the resident expressed concerns, she wants to be able to go outside while at the facility. She does not like to stay in her room or in bed, she likes to be out and about. It's not fair that the smokers get to go out and non-smokers don't. She stated that so many people here would like to go out but don't get to. We have been asking this for months and nothing happens. Review of Resident R5's care plan dated 3/25/25 indicated it is important for R5 to go outside when the weather is good and enjoy eating/drinking, playing games, gardening, sitting, talking, walking, bird watching, and wildlife observing. During an interview on 7/15/26, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were treated in a manner that promotes his/her quality of life and to facilitate resident self-determination through support of resident choice. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility's infection control policies and procedures and staff interviews it was determined that the facility failed to implement an antibiotic stewardship program for six of 12 months (January 2026, February 2026, March 2026, April 2026, May 2026, June 2026).Findings include:Review of the facility policy Antibiotic Stewardship last reviewed 3/20/26, indicated the Antibiotic Stewardship will focus on monitoring use of antibiotics, improving antibiotic use by avoiding unnecessary or inappropriate antibiotics. The antibiotic stewardship process will be overseen and managed by the Infection Preventionist who uses expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotics starts, monitoring adherence to evidence based, published criteria during the evaluation and management of treated infections; and reviews antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. The will works collaboratively with the medical director, pharmacist, nursing and administrative leadership. Review of the facility's Infection Control surveillance for January 2026-June 2026 failed to include documentation to indicate that antibiotic monitoring was completed, previous six months was unable to be located for review (July 2025- December 2025).During an interview on 7/16/26, at 11:00 a.m. the Infection Preventionist confirmed that the facility failed to implement an antibiotic stewardship program.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for 17 of 24 residents (Resident R6, R16, R36, R51, R58, R59, R60, R67, R75, R93, R96, R105, R109, R129, R130, R134, and R139).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. -Resident R6 had an MDS completed on 6/23/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R6 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R6 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R6 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R16 had an MDS completed on 5/13/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R16 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R16 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R16 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R36 had an MDS completed on 7/5/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R36 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R36 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R36 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R51 had an MDS completed on 6/19/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R51 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R51 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R51 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R58 had an MDS completed on 6/19/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R58 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R58 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R58 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R59 had an MDS completed on 7/3/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R59 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R59 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R59 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R60 had an MDS completed on 7/7/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R60 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R60 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R60 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R67 had an MDS completed on 7/4/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R67 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R67 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R67 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R75 had an MDS completed on 5/8/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R75 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R75 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R75 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R93 had an MDS completed on 5/8/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R93 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R93 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R93 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R96 had an MDS completed on 5/11/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R96 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R96 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R96 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R105 had an MDS completed on 5/11/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R105 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R105 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R105 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R109 had an MDS completed on 6/26/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R109 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R109 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R109 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R129 had an MDS completed on 6/26/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R129 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R129 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R129 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R130 had an MDS completed on 6/21/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R130 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R130 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R130 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R134 had an MDS completed on 5/11/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R134 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R134 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R134 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R139 had an MDS completed on 5/4/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R139 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R139 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R139 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 7/16/26, at approximately 12:00 p.m. the Licensed Practical Nurse Assessment Coordinator (LPNAC) confirmed that Resident R16's MDS Assessment was incorrect, and that when a resident is at least sometimes understood, the BIMS and Resident Mood Assessments should be completed. During an interview on 7/16/26, at approximately 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for 17 of 24 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for three of 42 licensed nurses (Licensed Practical Nurse (LPN) Employees E1, E3 and E4).Review of the facility policy, Cardiopulmonary Resuscitation (CPR) dated [DATE], indicated Licensed nursing staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. Online-only certification is not acceptable.On [DATE], the Nursing Home Administrator (NHA) provided a list of 42 currently employed licensed nurses.Review of the CPR certification cards for LPN Employees E1, E3 and E4 indicated the certification was for an online-only CPR class, for non-healthcare providers, that did not include a hands-on session.During an interview on [DATE], at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that facility nursing personnel maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for three of 42 licensed nurses.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(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 R151).Findings include: Review of facility policy Medication Administration dated 3/20/26, indicated Clients are allowed to self-administer medications when specifically authorized by the prescriber, the center's Interdisciplinary Team (IDT), and in accordance with procedures for self -administration of medications and state regulations. Review of the clinical record indicated Resident R151 was admitted to the facility on [DATE]. Review of Resident R151's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/24/26, indicated diagnoses of hyperlipidemia (high levels of fats in the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and depression. During an observation on 7/13/26, at approximately 10:00 a.m. Resident R151 was observed lying in bed, asleep. On the bedside table revealed a cup of seven pills. Review of Resident R151's physician orders failed to include an order for self-administration of medications. Review of Resident R151's care plan failed to address self-administration of medications. During an interview on 7/13/26, at approximately 10:30 a.m. Registered Nurse (RN) Employee E21 confirmed he left the cup of medication on Resident R151's bedside table and confirmed the facility failed to determine whether it was safe to self-administer medications. During an interview on 7/15/26, at approximately 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to determine whether it was safe to self-administer medications. 28. Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain that call lights were accessible for two of eight residents as required (Resident R10 and R53).Findings include: The facility policy Call Lights dated 3/20/26, indicated Patients will have a call light or alternative communication device at each patient's bed side, toilet, and bathing room to allow patients to call for assistance when unattended. Staff will respond to call lights and communication devices promptly. Review of Resident R10's clinical record indicated admission to the facility on 6/3/24. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/19/26, indicated diagnoses of non alzheimers dementia (dementia caused by vascular, lewy body or frontotemporal dementia), diabetes (body does not use insulin effectively), and seizure disorder (sudden disruptions of the brain's normal electrical activity). Review of Section GG: Functional Abilities GG0130, indicated that Resident R10 is independent with toileting hygiene and GG0170 toilet transfers independent. During an interview and observation on 7/13/26, at approximately 10:30 a.m. Resident R10 stated she has the call light next to her bed and one in the bathroom if she needs it. When asking Resident R10 what she would do if she needed help in the bathroom, she stated, I would use the call light next to the toilet. The call light cord in the bathroom was wrapped around the grab bars rendering it inoperable. Review of Resident R53's clinical record indicated admission to the facility on 4/28/22. Review of Resident R53's MDS dated [DATE], indicated a diagnosis of foot drop (inability to lift the front part of the foot), non Alzheimer's dementia (dementia caused by vascular, Lewy body or frontotemporal dementia), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear and uneasiness). Review of Section GG: Functional Abilities GG0130, indicated that Resident R53 is independent with toileting hygiene and GG0170 toilet transfers independent. During an interview and observation on 8/5/25, at approximately 10:45 a.m. Resident R53 stated she uses the bathroom and would use the bathroom call light pull cord if she needs help. The call light cord in the bathroom was wrapped around the grab bars rendering it inoperable. During an observation and interview on 7/13/26 at 11:45 a.m. Employee E1 Licensed Practical Nurse (LPN) confirmed the call light cords were wrapped around the grab bars rendering them inoperable for Residents R10 and R53. During an interview on 7/15/26 at 2:00 p.m. the Nursing Home Administrator and Director of Nursing (DON) confirmed the facility failed to make certain that call lights were accessible. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for two of six reviewed days. Findings include: Observation conducted on 7/13/26, at approximately 9:00 a.m., revealed that nurse staffing information was posted in the main lobby on the reception desk. At that time, the nurse staffing information had the date of (7/10/26), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 7/13/26, at approximately 9:30 a.m., the NHA and DON confirmed the facility failed to post the required current facility information for staffing hours and the facility census. 201.18(b)(3) Management.

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to properly store and secure a medication cart, a treatment cart, and failed to store a prescribed alcoholic beverage in a secure location (two medical carts, and one alcoholic beverage).Findings include: Review of facility policy Storage of Medications reviewed [DATE], indicated medications and biologicals are stored properly, following manufacturers or pharmacy recommendations, to maintain integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Outdated, discontinued, contaminated, or deteriorated medications are immediately removed from stock and disposed of. Review of facility policy Alcoholic Beverages reviewed [DATE], indicated a physician order will be obtained for the consumption of alcoholic beverages. Alcohol supplied by the resident or resident representative is labeled with resident's name, room number, and date opened and stored in a secure location. During an observation on [DATE], at 10:45 a.m. a resident was leaving the Staff Development room with two cups in his hand, one was a paper cup from a popular Italian Ice establishment that contained hot coffee and requested help closing the door. Upon entering room to allow the resident to leave, two medication carts were noted in the room, unlocked, and accessible by residents, visitors, and other staff members. The contents of the Staff Development room included an unlocked red medical cart, an unlocked beige medical cart, an unlocked refrigerator, two broken wheelchairs, two locked file cabinets, teaching material for Nurse Aid training, a microwave, an instant k-cup single use coffee maker, and a broken electric reclining chair. The room had two entrance doors and neither door contained a locking mechanism. The red medical cart contained the following:-four glucose monitoring lancets (small, sharp, double-edged instrument primarily used to make tiny incisions or draw blood).-one blood glucose monitoring test strips, expired [DATE].-one glucometer-one pulse oximeter machine-six 21g (gauge, measurement used for medical needle sizes) butterfly needles used for blood draws-one 21g intravenous (IV) start needle-one 25-foot oxygen tubing-two 15-inch humidifier connector tubes-one box alcohol wipes- four face shields-four Yankauer bulb tip suction tip (rigid, curved or straight medical suction instrument used to clear secretions from the mouth and throat)-one six-foot IV line (flexible plastic tubing used in IV therapy to deliver fluids directly into the bloodstream)-three plastic PPE (Personal Protection Equipment) isolation gowns-two manual blood pressure cuffs-one adult oxygen face mask -one 340 ml (milliliters) pre-filled oxygen humidifier bottle-three 100 ml bottles of normal saline 0.9% (a sterile solution of sodium chloride dissolved in one liter of water; closely matches the natural salt and water balance in human blood); expired [DATE]-one irrigation tray with 60 ml piston syringe (sterile, single-use medical kit designed to flush fluids into body cavities, wounds, or urinary catheters (small tube that drains urine from the bladder)-one box adult flexible tracheostomy tube (medical device inserted into a patient's trachea [windpipe] to help them breathe; tracheostomy - surgically created opening, or stoma, through the front of the neck into the trachea) -two tracheostomy oxygen masks (specialized medical device designed to fit over a patient's neck stoma -one Ambu-bag (Artificial Manual Breathing Unit; hand-held medical device used to pump oxygen into the patient's lungs)-one box of 4x4 gauze sponge, including approximately 50 packages-one 1000 ml bag of Normal Saline 0.9% The beige medical cart contained the following:-one sterile drape (medical specialized germ-free sheet used to help prevent the spread of infections)-11 single-blade disposable razor bladesThe unlocked refrigerator contained the following:-white plastic bag covering a plate with liquid pooling in the bottom of the bag-a can of Celsius (sparkling or non-sparkling flavored drink with 200 mg (milligrams) of caffeine)-one multi-use vial of tuberculin skin test (TB; Mantoux test); expired 2/20-two open soda bottles -one unopened bottle of beer-one 66 oz (ounce) bottle of coffee creamer, undated, with very small amount of liquid remainingDuring an interview on [DATE], at 11:15 a.m. the Director of Nursing confirmed the above observations and confirmed the facility failed to properly store and secure two medical carts containing medication and biologicals, failed to properly store and secure an alcoholic beverage, and failed to properly secure a non-resident room that contained multiple hazards for resident safety.

Based on review of facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of four residents (Resident R99).Findings include: Review of the Facility Assessment dated 7/13/26, indicated that the facility will provide services for psychiatric/mood disorders. Included in the list of conditions treated was post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing a terrifying event), Review of the clinical record revealed that Resident R99 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/11/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), anxiety, and depression. Further review of the MDS failed to include a diagnosis of PTSD. Review of Resident R99's care plan initiated 8/5/25, failed to a plan of care developed for PTSD. Review of Resident R9's Social Services Assessment and Documentation dated 8/9/25, indicated that the patient did not report, and the medical record did not indicate, a history of trauma and/or PTSD. Review of Resident R9's Social Services Assessment and Documentation dated 2/19/26, indicated that the patient did not report a traumatic event such as physical or sexual assault, a natural disaster, or seeing someone be killed. Review of Resident R99's hospital discharge paperwork dated 8/5/26, indicated Resident R99 had been seen by a doctor due to having suicidal thoughts or actions. Review of a progress note dated 2/28/26, at 12:35 p.m. indicated Resident R99 has faced a traumatic event or experience in the past Review of a progress note dated 3/19/26, at 10:14 p.m. indicated Resident R99 had, a past psychiatric history of PTSD. During an interview on 7/16/26, at 9:35 a.m. Resident R99 stated she had been sexually molested as a child and had been in abusive relationships. During an interview on 7/16/26, at approximately 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of four residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for two of eight sampled residents (Residents R3 and R8).Findings include: Review of the facility policy Oxygen Therapy Administration reviewed on 3/20/26. The policy indicates replace disposable set-up every seven days. Date and store oxygen delivery device in treatment bag when not in use. Review of Resident R3's admission record indicated he was admitted on [DATE]. Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/6/26, indicated the diagnoses of cerebral palsy (a neurological disorder that affect body movement and muscle coordination, often caused by abnormal brain development or damage to the developing brain), hypertension (high blood pressure), and diabetes (body does not use insulin effectively). Review of Resident R3's current physician orders dated 5/15/26, indicated CPAP change or clean intake filter and disposable supplies (e.g. tubing) per manufacturer's instructions as needed and 5/30/26 order CPAP change or clean intake filter and disposable supplies (e.g., tubing) with soap and water, every night shift. Resident oxygen setting is 2 liters per minute every evening and night shift. Interview and observations on 7/13/26, at approximately 12:00 p.m. to 12:30 p.m., with Licensed Practical Nurse (LPN) Employee E1 and Respiratory Therapist (RT) Employee E2, confirmed Resident's R3 oxygen tubing connected to their oxygen concentrator was dated 6/30/26 and should have been changed weekly. Review of Resident R8's admission record indicated he was admitted on [DATE]. Review of Resident R8's MDS dated [DATE], indicated the diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), Multiple sclerosis (disease that causes breakdown of the protective covering of nerves, can cause numbness, weakness, trouble walking, vision changes and other symptoms), and diabetes (body does not use insulin effectively). Review of Resident R8's current physician orders dated 7/6/26, indicated oxygen 2 liters per minute as needed. Interview and observations on 7/13/26, at approximately 12:00 p.m. to 12:30 p.m., with Licensed Practical Nurse (LPN) Employee E1 and Respiratory Therapist (RT) Employee E2, confirmed Resident's R8 oxygen tubing connected to their oxygen concentrator was located in the resident's bathroom, blocked by an electric powered wheelchair, with oxygen tubing that was not in a treatment bag and was not labeled with a date. During an interview on 5/19/26, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for three of four quarterly meeting (August 2025 to March 2026).Findings Include: Review of the facility policy Center Quality Assurance Performance Improvement Process (QAPI) reviewed 3/20/26, indicated QAPI activities will be integrated across all care and service areas and include clinical care, quality of life, and resident choice.During an interview on 7/14/26, at 10:35 a.m. the Nursing Home Administrator (NHA) was unable to locate the sign-in sheets for the QAPI meetings from August 2025 through March 2026.During an interview on 7/16/26, at 10:00 a.m. the NHA confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members as required.28 Pa Code201.18(e)(1)(2)(3)(4)Management28 Pa Code211.12(d)(3)(5)Nursing Services

Based on a review of facility policy, resident interviews, and meal observations, it was determined that the facility failed to provide resident selected menu items for five of nine residents (Resident R4, R5, R6, R7, and R8).Findings include: Review of the facility policy Dining and Food Preferences dated 3/15/26, indicated that individual dining, food, and beverage preferences are identified for all residents and that the individual tray assembly ticket will identify food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. During an observation of the evening meal on 4/14/26, the following was observed: Resident R4's meal ticket indicated she was to receive a chef salad with five Italian dressings. The salad and dressing were not present on the meal tray delivered in the surveyor's presence. Resident R5 meal ticket indicated chocolate pudding. Resident R5 stated that she has advised the kitchen staff multiple times that she does not want chocolate pudding every day. Additionally, Resident R5 stated that she requests to receive a banana each morning, but only receives them two to three days per week. Resident R6's meal ticket indicated she was to receive ground molasses barbeque chicken and marinated cauliflower. Resident R6 received dry ground chicken without barbeque sauce and did not receive cauliflower. Resident R7's meal ticket indicated he was to a double entree. Observation of the meal tray prior to any being consumed confirmed Resident R7 did not receive a double entree. During an interview on 4/14/26, at approximately 6:00 p.m. Resident R8 stated that often the food received is not what she requested. The family member for Resident R8 stated that they never know what to expect for meals because the menu doesn't have dates and the meals don't follow the menu to figure out what week it is. During an observation on 4/14/26, at approximately 6:05 p.m. the menu posted in the resident hallway was noted to have Week One, Week Two, and Week Three, but with no dates or signage to indicate what was the current week. During an interview on 4/14/26, at 6:45 p.m., the Nursing Home Administrator confirmed that the facility failed to provide resident selected menu items for five of nine residents. 28 Pa. Code 201.18(b)(3) Management.28 Pa Code: 211.6(a) Dietary service.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate sexually inappropriate resident behaviors to ensure resident safety for one of five residents (Resident R3). Findings include: Review of facility Abuse Prohibition revised 11/14/25, indicated the Center will implement an abuse prohibition program through identification of possible incidents or allegations which need investigation and investigating of incidents and allegations. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 3/5/26, included diagnoses of chronic kidney disease (gradual loss of kidney function), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and depression. Review of Section C: Cognitive Patterns indicated that Resident R3 had moderate cognitive impairment. Review of the plan of care dated 11/12/25, indicated Resident R3 has the Tendency to exhibit sexually inappropriate behavior. Review of a progress note dated 11/12/25, at 2:53 p.m. indicated, CNA (nurse aide) reports to this nurse that resident was talking in appropriately to her. resident said to CNA when are you going to let me hit that. he then tried hitting CNA in the butt with a shirt. Review of a psychiatry note dated 12/22/25, indicated, Primary care reports to CRNP (nurse practitioner) that resident has been having inappropriate sexual behaviors towards CNAs and RNs (registered nurses) including groping private areas, making crude comments. Review of a progress note dated 3/3/25, at 3:43 a.m. indicated, Notified by CNA [Nurse Aide Employee E7] that resident had requested assistance with scratching his back as it was itching. CNA went into room to offer assistance and the resident then attempted to stick his hand between her legs and when he couldn't do that he proceeded to grab her buttocks. CNA visibly upset. [Local police] notified and report made as this'd is not resident's first time sexually harassing a CNA. Review of a psychiatry note dated 3/3/26, indicated, Staff report ongoing concerning behaviors including repeated requests for doors to be closed when female staff are present in the room, including during a recent blood draw with a female phlebotomist. Review of a psychiatry note dated 4/10/26, indicated, Since last evaluation, 1:1 supervision has been reinstated per corporate request. Another reported incident earlier today in which the resident made an inappropriate verbal remark to a staff member (let me hit that) occurred. Overall, presentation remains consistent with neurocognitive disorder with behavioral disinhibition and impaired judgment, likely contributing to recent inappropriate verbal behavior. Hard to determine whether this is true cognitive impairment or secondary gain concerns. Despite remorse and partial awareness, risk for recurrence remains given cognitive limitations. Notes from primary care reviewed also consistent with that these issues could be related to chronic long standing alcohol related dementia or could also be a desire for secondary gain. On 4/14/26, review of facility-provided investigation documents failed to reveal steps taken to ensure that Resident R3 had not been inappropriate with peer residents in addition to staff members. During an interview on 4/14/26, at approximately 3:00 p.m. the Director of Nursing confirmed Resident R3 had known sexually inappropriate behaviors and that an investigation to ensure that Resident R3 had not been inappropriate with peer residents in addition to staff members had not been completed. During an interview on 4/14/26, at approximately 6:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to investigate sexually inappropriate resident behaviors to ensure resident safety for one of five residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (c) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2) Nursing services.

Based on review of facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to correctly identify residents during medication administration to make certain that residents are free of significant medication errors for one of four residents (Resident R1). This was identified as past noncompliance.Findings include: Review of the facility policy Identification of Patient dated 7/1/25, indicated, All patients will receive a patient identification bracelet upon admission. Refusal will be documented in the medical record. Review of facility policy Medication Errors dated 7/1/25, indicated Significant Medication Error means one which causes the patient discomfort or jeopardizes their health and safety. To prevent medication errors and ensure safe medication administration, nurses should very the following information: Right medication, dose, route, and time of administration; Right patient and right documentation. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood) and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of Resident R1's physician order dated 3/17/26, indicated Resident R1 received outpatient dialysis on Monday, Wednesday, and Friday. Review of facility submitted information dated 3/18/26, indicated, On March 18, 2026, an individual was transported from dialysis to the facility by [Transportation Company] and the driver stated 'I'm here to drop off [Resident R1's first name] from dialysis. The receptionist directed the driver to [Resident R1's room], based on the expected return of newly admitted resident, [Resident R1], who had been sent out for dialysis earlier that morning at approximately 05:00 am. At approximately 11:45, upon arrival at the facility, staff entered the resident room and a photo of the individual was obtained as per our admission process. The Day shift nurse evaluated the resident name [Resident R1's first name], verified the photograph in PCC, and the individual verbally confirmed his name as [Resident R1's first name]. Based on this identification, the nurse administered scheduled medications, including Flomax (medication to treat an enlarged prostate), Sinemet (medication to treat Parkinson's disease), Vitamin D and a multivitamin. Subsequently, the facility received a call from another facility [Facility Two, approximately seven miles away] indicating that one of their residents, also named [Resident R1's first name], had been transported to the wrong facility. An investigation was initiated immediately, and it was determined that the transportation company had transported and dropped off the wrong resident [Resident R1's first name] to our facility. It was determined that the individual was not [Resident R1] that was admitted to our facility on 3/18/2026. A call was placed to [Facility Two], and transportation was notified and arrived to pick the resident [Non-facility resident] up and transport him back to the facility. [Non-facility resident] appeared comfortable, no adverse reactions noted prior to transfer. Resident documents from dialysis were reviewed and the resident had no known allergies. A call was placed to [Facility Two] and the nurse was informed that the resident (Resident R1) was doing fine. Review of an employee statement written by Registered Nurse (RN) Employee E5 dated 3/18/26, indicated, This event occurred on 3/18/26 at 1145. I went into [Resident R1's room number] for an admission skin assessment and noticed his profile was not completed. I took his picture. When I asked Mr. [Resident R1] if that was his name and to repeat his name to me, and he mumbled and hand gestured, acknowledging the fact that this was him. He didn't answer any of my questions directly but didn't deny being [Resident R1]. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E1 dated 3/18/26, indicated, On 3-18-26 at 11:45 a.m. pt (patient) [Resident R1] returned from dialysis to his room. This pt left for dialysis at 5am before my shift and he returned from dialysis around 11:45 a.m. At 11:54 a.m. I went into the room to administer his medication. Asked his name he nodded and answered yeah. And the pt does not have name band, but has picture in profile. I gave medication as ordered and pt tolerated medication well. Pt call bell within reach and left room. Review of an undated employee statement written by Administrative Employee E2 (indicated, On [DATE] on or around 12:15 PM, as I was passing on the hallway, the receptionist waved to me and said They said the new admission is said to be confused and he is probably not our [Resident R1's first name], I guess transportation brought him to the wrong facility. I immediately notified [Nursing Home Administrator]. He immediately left his office and went to the room to follow up. I also went to the admission office and notified the Admissions Director to follow up on the new admission based on the information the receptionist shared. Review of an employee statement written by Receptionist Employee E4 dated 3/18/26, indicated that at 11:45 a.m. [Transportation Company] arrived at the center. Driver sated I am returning [Resident R1's first name] from dialysis, what room is he? I repeated, 'You have [Resident R1's first name] from dialysis. The driver said yes. I told him [Resident R1's room number]. At approximately 12pm, I answered the phone. I was [Transportation Company]. They asked me to check if [Resident R1] was in his room. I asked [Employee E3] to check [Resident R1's room number] to see if the resident was in there she said yes. I then received another phone call from [Facility Two] stating we have the wrong resident. I notified the NHA and Employee E2. I received another call regarding it being the wrong resident and I then notified the NHA. Review of an employee statement written by Administrative Employee E3 dated 3/19/26, indicated, On March 18 2026 around 12:30 pm I was walking to [Resident R1's room] to complete a 72-hour financial meeting with [Resident R1] when [receptionist [NAME] E4] was on the phone and asked me to check an see if he was in his room. I said yes that is where I am heading now. I knocked on the door and said Mr. [Resident R1's last name] as I looked at the gentleman sitting in a chair next to the bed by the door. I had never seen what [Resident R1] looked like he was admitted Tuesday and I was not at work, then was out to an appointment in the morning when I received the paperwork He looked up at me and said Huh, I said hello [Resident R1's first name] I am here to go over some paperwork with you. He said when am I going back to [Facility Two]. I stated he would have to speak with the doctor of physical therapist, I then asked if I could speak to him about his insurance coverage or if there is someone in his family I should call. He said huh? So I leaned in and spoke a little louder and repeated the question. He replied the meal was excellent but I want to go home now. I said ok Mr. [Resident R1's last name] I will be back. I walked back to the office and as I passed [receptionist Employee E4] I said he's there I am not sure he knows who or where he is. I went and explained the conversation with [[NAME]] and she recommended having [[NAME]] call the family. Review of an employee statement written by RN Employee E6 dated 3/18/26, indicated, At approximately 1215 p.m. NHA notified us of the wrong resident being transported to the facility. I accompanied the NHA to the room. I asked the resident to acknowledge his name, he mumbles, I checked both arms for an ID band, no band present. I looked in the bag on the back of the WC (wheelchair), I saw leg rest in the bag when we applied the leg rest. I also found a dialysis communication binder in the back of the WC with the resident's name on the outside and a face sheet with the resident's photo. We brought the resident out to the lobby and remained with him until transport arrived at the center to take the resident back to his facility. At approximately 1pm a driver walked into the building and the resident [External Resident R2] said, '[Driver's name], that's my ride.' I confirmed with the driver that his name was [Driver's name]. The driver confirmed and I asked if he usually transports this resident to/from dialysis. He said yes multiple days a week but not every time. At approximately 1:30 p.m. Resident (External Resident R2) left the facility with [Transportation Driver] to be transported back to his facility. Resident face sheet was checked resident had no known allergies, resident showed no signs or symptoms of adverse reaction from medication that was administered. NHA placed call to [Facility Two] to notify them that the resident left the facility to return to them and what medications were administered at our facility. On 3/18/26, the facility initiated a plan of correction that included:Resident identification immediately verified.Initial audit of all residents conducted to verify ID bands are present and match phot and identification listed in the electronic medical record.Staff reeducation on Identification of Patient policy.Staff reeducation on ensuring resident is identified using two patient identifiers via ID ban, photo ID in the electronic medical record, or resident verbally supplies full first and last name, date of birth (if capable) while being evaluated or prior to undergoing procedures/treatments.State survey agency notified.Quality Assurance and Performance Improvement (QAPI) ad hoc meeting completed. New admissions, residents returning from appointments will have their identification verified by the receptionist using ID band, verbal confirmation of full name, paperwork prior to sending to room. New admissions will have a photo taken upon arrival and uploaded to the electronic medical record for identification purposes.Director of Nursing to conduct audits weekly for four weeks, then monthly for two months, of ten residents to verify ID bands in place, and that it matches current ID/photo in the electronic medical record. Results of the audits to be presented at the QAPI meetings for review and recommendations. On 4/14/26, the initial audit, staff education, and ad hoc QAPI meeting were verified to be completed by 3/20/26. During an interview on 4/14/26, at approximately 6:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to correctly identify residents during medication administration to make certain that residents are free of significant medication errors for one of four residents. This was identified as past noncompliance. 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on a review of facility policy, clinical records, staff interviews, and facility reported incident, it was determined that the facility failed to make certain that residents were protected from harmful chemicals that resulted in actual harm for a resident (Resident R1) when the resident ingested ethylene glycol (chemical found in antifreeze) resulting in hospitalization. This failure created an Immediate Jeopardy situation for one of 108 residents. Findings include: Review of the facility policy, Accidents/Incidents, indicated the facility will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred involving a resident who is receiving services. The policy is to provide standards for review and investigation of accidents/incidents and to determine the root cause and contributing factors, identify measures to reduce further occurrences and adverse outcomes. Review of the Environmental Protection Agency (EPA - a federal agency, that sets and enforces rules and standards that protect the environment) publication, Label Review Manual: Chapter Seven, dated 03/2018, indicated the following:Table 3. Typical Statements for Acute Oral ToxicityCategory Signal Word Statement I (one) DANGER; POISON Fatal if swallowed.II (two) WARNING May be fatal if swallowed.III (three) CAUTION Harmful If swallowed.IV (four) CAUTION (optional) No statement is required, May use Category III statement. Review of the Safety Data Sheets (SDS - provides essential information about hazardous chemicals) for Peak 50/50 Prediluted Antifreeze (substance added to liquid to lower its freezing point; antifreezes commonly added to cooling systems of automobile engines) dated 1/1/20, indicated in Section 2: Hazards Identification that Peak 50/50 antifreeze is designated to have acute oral Toxicity Category of 4. Harmful if swallowed. Repeated Exposure is Category 2: May cause damage to organs (kidneys) through prolonged or repeated oral exposure. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included toxic effects of glycols (suspected antifreeze oral consumption), Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of the MDS Section C: Cognitive Patterns. Question C0500: BIMS Summary Score was 15. Review of a Medical Provider Note progress note dated 9/15/25, at 2:02 p.m. indicated the facility providers were aware of Resident R1's prior attempts of self-harm: Pt (patient) had recent hospitalization to [hospital] 201 (voluntary admission) for Seroquel (anti-psychotic medication) overdose and requested for the Seroquel to be increased. Request was declined. Review of hospital Discharge Clinical Summary dated 10/25/25, indicated Resident R1 was admitted to the hospital on [DATE], with acute kidney injury (AKI, kidneys suddenly lose their ability to filter waste from the blood), and metabolic acidosis due to ethylene glycol (when ethylene glycol is ingested causing kidney damage). Further review of the hospital progress notes indicated the following: -On 10/27/25, at 11:57 a.m. a practitioner progress note indicated the emergency room evaluation was consistent with ethylene glycol toxicity. Resident R1 does have a history of cocaine use and Seroquel overdose.-On 10/28/25, at 11:39 a.m. an acute progress note indicated Resident R1 was hospitalized from [DATE] through 10/25/25, for suspected self-harm attempt with injection of ethylene glycol that requires ICU (intensive care unit) with intubation (placed on a ventilator to assist with breathing), and temporary dialysis. Resident R1 also had a recent psychiatric hospital admission.-On 10/30/25, at 12:00 a.m. an initial psychiatry progress note indicated Resident R1 has an extensive psychiatric history including inpatient hospitalization. History of possible self-harm attempts which the resident denies. Requests for Seroquel increase, not advisable due to history of overuse. Review of the care plan updated 10/30/25, indicated Resident R1 had potential risk for ideations of self-harm related to PTSD (post-traumatic stress disorder (stress after trauma), glycol toxicity, and hallucinations (a false perception of sensory experiences, they seem real but are not). Review of a facility submitted documents dated 12/21/25, indicated Resident R1 was noted to have altered mental status (change in a person's usual mental function) and was transferred to the local emergency room for evaluation. On 12/22/25, the facility received a telephone call from the hospital with concerns that Resident R1 had ingested antifreeze and requested staff to search her room for suspicious items. Staff found a gallon bottle of Peak 50/50 Prediluted Antifreeze in Resident R1's room. During an interview on 1/13/26, at 1:38 p.m. Registered Nurse (RN) Unit Manger Employee E1 stated a physician from the hospital called due to suspicious labs. RN Employee Unit Manager stated he was not aware of Resident R1's history of self-harm. Licensed Practical Nurse (LPN) Employee E2 searched Resident R1's room and found the jug of antifreeze in a yellow dollar general bag, the cap still contained the plastic seal around the lid so he thought the jug was not open, but he was able to twist the lid off without breaking the plastic seal around the lid. He stated he did not see a receipt in the bag. RN Unit Manager Employee E2 stated Resident R1's usual behavior was quiet, she stayed to herself, didn't use the call bell, and either kept her door shut or the privacy curtain closed. During an interview on 1/13/26, at 1:52 p.m., LPN Employee E2 stated on 12/22/25, the hospital called regarding abnormal labs and asked if someone could search Resident R1's room for antifreeze. The antifreeze gallon was found in Resident R1's closed cupboard in a yellow dollar store bag. A receipt was not included. LPN Employee E2 stated Resident R1 door-dashed a lot (of deliveries) in the evenings. LPN Employee E2 stated she did not have any suspicions nor noticed any abnormal behavior the week prior to the incident. The Nursing Home Administrator (NHA) and Director of Nursing were made aware that an Immediate Jeopardy situation existed for residents on 1/13/26, at 3:10 p.m. and a corrective action plan was requested. On 1/13/26, at 7:30 p.m. an acceptable Corrective Action Plan was received which included the following interventions:1. Initial audit will be completed to determine any resident with diagnosis of self-harm attempt or ideation and care plans will be updated with interventions.2. DON or designee will educate staff on policy of accidents policy OPS100 prior to the start of their next shift.3. The facility will establish a protocol related to door dash and deliveries, it will be shared at the AD HOC resident council, to families via regroup, and staff with be educated.4. DON or designee will complete a weekly audit for eight weeks to determine if any resident with self-harm attempts and/or ideation is placed on psych services, care plan initiated, and interventions added to the Kardex.5. Results of the audit will be reported to the Quality Assurance Performance Improvement (QAPI) Committee monthly. During an interview on 1/14/26, at 9:15 a.m. RN Employee E4 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 9:20 a.m. Nurse Aid (NA) Employee E5, E6, and E7, Housekeeping Employee E8, and LPN Employee E9 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:22 a.m. RN Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:23 a.m. LPN Employee E11 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:25 a.m. Housekeeper Employee E12 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:27 a.m. LPN Employee R13 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:27 a.m. LPN Employee E10 and E11 confirmed they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 9:30 a.m. LPN Employee E14 , and NA Employee E15 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:33 a.m. Physical Therapy Assistance (PTA) Employee E17 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:35 a.m. Laundry Employee E18 confirmed they received education on safety related third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:43 a.m. Front Desk Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 10:00 a.m. RN Unit Manager Employee E1 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:00 a.m. RN Employee E20 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:00 a.m. NA Employee E21 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:01 a.m. Therapy Director Employee E22, NA Employees E23 and E24 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:04 a.m. NA Employee E25 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:08 a.m. Assistant Director of Therapy Employee E26, and NA Employees E27 and E28, confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:12 a.m. Physical Therapy (PT) Employee E29 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:15 a.m. Speech Therapy (ST) Employee E34 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:21 a.m. Maintenance Director Employee E30, and Maintenance worker Employee E31 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:30 a.m. Physical Therapy Assistant (PTA) Employee E32 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:33 a.m. Central Supply Coordinator Employee E33 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:35 a.m. Certified Occupational Therapy Assistant (COTA) Employee E35 and PTA Employee E36 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:37 a.m. Scheduler/Payroll Employee E37 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. The Immediate Jeopardy was removed on 1/14/26, at 2:38 p.m. after it was verified that the corrective action plan was implemented. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (a)(b)(1)(3)(e)(1) Management.28 Pa. Code 211.5(f)(h) Clinical records.28 Pa. Code 211.11(c)(d) Resident care plan.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility documentation, observation and staff interview it was determined that the facility failed to ensure that the residents received appropriate treatment and services to correct assessed problems associated to an event of self-harm for one of two residents reviewed (Resident R1) resulting in actual harm, transfer to the hospital (Resident R1); and the investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, resulting in an Immediate Jeopardy situation for one of 108 residents (Resident R1). Findings include: Review of facility policy Behaviors: Management of Systems indicated that based on the comprehensive assessment, staff must ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included toxic effects of glycols (suspected antifreeze oral consumption), Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and depression. Review of Resident R1's care plan updated 10/30/25, indicated Resident R1 had potential risk for ideations of self-harm related to PTSD (post-traumatic stress disorder (stress after trauma), glycol toxicity, and hallucinations (a false perception of sensory experiences, they seem real but are not). Review of Resident R1's physician orders from 10/25/25, through 12/3/25, revealed orders for psychiatry/psychology consultation and pharmacy orders for medications to treat insomnia, anxiety, depression, and overdose reversal medications. Review of the progress notes indicated the following:On 9/15/25, at 2:02 p.m. a Medical Practitioner Note stated Pt (patient) had recent hospitalization to [hospital] 201 (voluntary admission) for Seroquel (anti-psychotic medication) overdose and requested for the Seroquel to be increased. On 9/25/25, at 6:41 p.m. a general progress note indicated Resident R1 was to be discharged at 5:00 p.m. on 9/25/25, but when they went into Resident R1's room, her belongings were gone. When they called Resident R1 she was already at home. Review of hospital Discharge Clinical Summary dated 10/25/25, indicated Resident R1 was admitted to the hospital on [DATE], with acute kidney injury (AKI) (kidneys suddenly lose their ability to filter waste from the blood), and metabolic acidosis due to ethylene glycol (when ethylene glycol is ingested causing kidney damage). Further review of the progress notes indicated the following:-On 10/27/25, at 11:57 a.m. a Practitioner progress note indicated the emergency room evaluation was consistent with ethylene glycol toxicity. Resident R1 does have a history of cocaine use and Seroquel overdose. -On 10/28/25, at 11:39 a.m. an acute progress note indicated Resident R1 was hospitalized from [DATE] through 10/25/25, for suspected self-harm attempt with ingestion of ethylene glycol that required ICU (intensive care unit) with intubation (placed on a ventilator to assist with breathing), and temporary dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately), Resident R1 also had a recent psychiatric hospital admission. -On 10/30/25, at 12:00 a.m. an initial psychiatry progress note indicated Resident R1 has an extensive psychiatric history including inpatient hospitalization. History of possible self-harm attempts which the resident denies. Requests for Seroquel increase, not advisable due to history of overuse. Review of behavior charting for October 2025, revealed three of six shifts without documented behavior monitoring (50% missed documentation). Review of behavior charting for November 2025, revealed 24 of 90 shifts without documented behavior monitoring (approximately 27% missed documentation). Review of behavior charting for December 2025, revealed 26 of 61 shifts without documented behavior monitoring (approximately 43% missed documentation). Further review of Resident R1's medical records failed to include consistent lack of any behavioral health interventions to address residents previous histories of suicidal attempts/ideations. Review of a facility submitted documents dated 12/21/25, indicated Resident R1 was noted to have altered mental status (change in a person's usual mental function) and was transferred to the local emergency room for evaluation. On 12/22/25, the facility received a telephone call from the hospital concerning Resident R1 possibly ingesting antifreeze and requested staff to search her room for suspicious items. Staff found a gallon of Peak 50/50 Prediluted Antifreeze in Resident R1's room. During an interview on 1/13/25, at 3:35 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated they were unaware of Resident R1's history of self-harm, and the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services. An immediate jeopardy situation was identified to the NHA on 1/13/26, at 3:46 p.m. the facility failed to ensure appropriate treatment and services to attain the highest practicable mental health and psychosocial well-being were provided for Resident R1, resulting in hospitalization from ingesting antifreeze, and had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services. The immediate corrective action plan included the following interventions: 1. Initial audit will be completed on current and new admissions to determine any resident with a DX (diagnosis) of suicide attempt or suicidal ideation have care plans that will be updated with interventions 1/13/26.2. NHA or designee will educate admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission. Prior to the start of their next shift, DON or designee will educate staff related to any new admission coming in with a history of past attempts for self-harm on the plan of care needs.3. DON or designee will complete a weekly audit on new admissions for eight weeks to determine if any resident with history of suicide attempt or suicidal ideation is placed on psych services, care plan initiated and interventions added to Kardex4. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.During an interview on 1/14/26, at 9:15 a.m. RN Employee E4 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 9:20 a.m. Nurse Aid (NA) Employee E5, E6, and E7, Housekeeping Employee E8, and LPN Employee E9 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview During an interview on 1/14/26, at 9:22 a.m. RN Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:23 a.m. LPN Employee E11 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:25 a.m. Housekeeper Employee E12 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:27 a.m. LPN Employee R13 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:27 a.m. LPN Employee E10 and E11 confirmed they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 9:30 a.m. LPN Employee E14 , and NA Employee E15 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:33 a.m. Physical Therapy Assistance (PTA) Employee E17 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:35 a.m. Laundry Employee E18 confirmed they received education on safety related third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 9:43 a.m. Front Desk Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 10:00 a.m. RN Unit Manager Employee E1 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:00 a.m. RN Employee E20 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:00 a.m. NA Employee E21 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:01 a.m. Therapy Director Employee E22, NA Employees E23 and E24 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:04 a.m. NA Employee E25 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:08 a.m. Assistant Director of Therapy Employee E26, and NA Employees E27 and E28, confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:12 a.m. Physical Therapy (PT) Employee E29 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:15 a.m. Speech Therapy (ST) Employee E34 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:21 a.m. Maintenance Director Employee E30, and Maintenance worker Employee E31 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:30 a.m. Physical Therapy Assistant (PTA) Employee E32 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:33 a.m. Central Supply Coordinator Employee E33 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During a group interview on 1/14/26, at 11:35 a.m. Certified Occupational Therapy Assistant (COTA) Employee E35 and PTA Employee E36 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. During an interview on 1/14/26, at 11:37 a.m. Scheduler/Payroll Employee E37 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview. The Immediate Jeopardy was removed on 1/14/26, at 2:38 p.m. after it was verified that the corrective action plan was implemented. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18(a) Management28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.5(h) Clinical records28 Pa. Code 211.11(c) Resident care plan28 Pa. Code 211.11(d) Resident care plan28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.16(a) Social services

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of twelve residents (Resident R19). This failure created an immediate jeopardy situation for 12 of 12 residents (Residents R19, R4, R17, R20, R21, R22, R23, R24, R25, R26, R27, and R28). This was identified as past non-compliance. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screening test that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the facility policy Elopement of Patient dated 10/24/24, indicated that patients identified as at risk, an interdisciplinary elopement prevention patient-centered care plan will be developed with patient participation and patient representative when applicable. Review of facility provided documentation indicated that on 4/4/25, an Appointment Escort Protocol was developed. Within that protocol it stated, Any resident with a BIMS lower than 13 will require an appointment escort. Review of medical records on 4/24/25, 12 of 49 residents with physicians' orders that indicated they may leave the facility unaccompanied; the following residents were noted: Resident R4, BIMS score of 7 on 3/11/25. Resident R17, BIMS score of 7 on 4/21/25. Resident R20, BIMS score of 7 on 4/22/25. Resident R21, BIMS score of 5 on 4/14/25. Resident R22, BIMS score of 0 on 2/19/25. Resident R23, BIMS score of 4 on 4/22/25. Resident R24, BIMS score of 7 on 2/6/25. Resident R25, BIMS score of 6 on 3/23/25. Resident R26, BIMS score of 3 on 4/11/25. Resident R27, BIMS score of 5 on 2/22/25. Resident R28, BIMS score of 4 on 4/19/25. None of these residents made attempts to leave the facility. During an interview on 4/24/25, at 11:47 a.m. Nurse Practitioner Employee E6 confirmed that residents with severe cognitive impairment should not leave the facility unaccompanied and confirmed that new residents who have not yet been seen by the provider should not have orders to leave the facility unaccompanied until after the provider has seen them. Review of the clinical record revealed Resident R29 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), anemia (too little iron in the body causing fatigue). Review of Section C: Cognitive Patterns revealed a BIMS score of 6. Review of an Elopement Evaluation completed on 2/28/25, indicated Resident R19 was not at risk for elopement. Review of the physician's order dated 2/28/25, indicated Resident R19 Patient may leave Center unaccompanied when arranged by the facility. Review of Resident R19's plan of care for initiated 2/28/25, did not include goals and interventions related to elopement. Review of a progress note dated 4/3/25, at 4:11 p.m. indicated Notified by driver that resident was not able to be found from his doctor's appt today. Unable to locate resident. County 911 called at 1607 (4:07 p.m.) full description of resident and clothing given. Missing persons report filed. Provider notified, Daughter unable to be reached via phone, office has no idea of whereabouts. Review of a progress note dated 4/3/25, at 6:14 p.m. indicated resident was found by local police at his residence. Resident R19 informed police, he called an Uber from his appointment and went home. Review of a progress note dated 4/3/25, at 8:24 p.m. indicated that Resident R19 located in community at his listed place of residence by transport driver and NHA (nursing home administrator) with police escort. Resident refused to return to facility and signed AMA (against medical advice) documentation after being educated on risks of not returning in an earlier conversation by this writer (Director of Nursing) and [local police department] officer. Resident verbalized understanding of risks. 911 was called to take resident to the hospital for RUA PICC (right upper arm, peripherally inserted central catheter) removal. Social Services to notify APS (Adult Protective Services) of AMA. Review of facility submitted information dated 4/4/25, indicated that on 4/3/25, at 3:30 p.m. Resident R19 went by [facility] transport van to his physician. follow up appointment. After the appointment the physician's office was to call for Resident R19 to be picked up by the facility. When no call was received the driver went back to the physician's office after calling and being told they took Resident R19 to the lobby. The driver was unable to locate Resident R19, he searched the building, talked to the staff at the office and called the facility to notify them that resident was unable to be located at the office. Resident was not exit seeking while in the facility. Review of a phone interview completed on 5/1/25, by the NHA with Transportation Employee E22 indicated, Resident was alert enough to speak to me while heading to his appointment on 4-3-2025 and seemed fine to go to his appointment. Throughout the whole day [Resident R19] seemed fine and was able to have a fluent conversation with me about his life, sports, and his housing situation. He did not seem confused at all and was very with it the entire day as we interacted. Review of an employee statement dated 5/1/25, written by LPN Employee E23 indicated, I was the primary nurse on 4/3/25 for [Resident R19]. There was no concern or confusion noted with the patient. He was able to participate in care and make decisions appropriately. Review of an electronic communication from Nurse Practitioner Employee E6 dated 5/1/25, at 1:19 p.m. indicated, On 4/3/25, patient [Resident R19] was appropriate for making his own medical decisions and there was no concern for him going to appointments without an escort. During a phone interview on 5/1/25, at approximately 1:30 p.m., Resident R19 stated he 'hated it there and left when he had the opportunity. The NHA and the DON were made aware that an Immediate Jeopardy situation existed for Residents R19, R4, R17, R20, R21, R22, R23, R24, R25, R26, R27, and R 28 on 5/1/25, at 4:42 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 5/1/25, at 4:42 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions: -Complete AMA (against medical advice) discharge at residence. -Emergency services called for hospital transfer for PICC removal. -Notification of Adult Protective Services. -Notification of Ombudsman. -Review of escort protocol. -Education to staff on sending residents to appointments with escorts. -Elopement book update. -Wellness check on resident. -Elopement drills every shift. -Validation of appointment returns for three months. -Developed protocol of offices calling building/driver for return and not putting residents in the lobby. -Daily review in morning meeting of upcoming appointments and if escorts are needed. -Update care plans. This plan was implemented on 4/4/25 and completed by 4/22/25. Based on previous review of facility plan of correction actions, the Immediate Jeopardy was removed on 5/1/25, at 4:43 p.m. when the action plan implementation was verified. During an interview on 5/1/25, at approximately 5:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision during resident transfers that resulted in the actual harm of a skin tear for one of three residents, failed to ensure residents with severe cognitive impairment are not provided orders to leave the facility unaccompanied for 13 of 66 residents, and failed to provide adequate supervision to prevent elopement for one of twelve residents. This failure created an immediate jeopardy situation for one of twelve residents. This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain that residents with suprapubic urinary catheters received appropriate treatment and services consistent with professional standards during catheter care by monitoring placement and skin, changing the catheters and providing care, resulting in actual harm as evidenced by penile split and traumatic insertion and removal for one of three residents (Resident R64) and failure to change a urinary catheter every 30 days as ordered for one of three residents (Resident R2). Findings include: Review of facility policy, titled Catheter: Urinary -Justification for Use dated 1/3/24, with a previous review date of 1/24/23, indicated, If patients' situation meets any of the indwelling catheter criteria, obtain physician order, include in care plan and follow Catheter: Indwelling Urinary- Care of procedure. Review of facility Procedure titled Catheter: Indwelling Urinary - Insertion dated 1/3/24, with a previous review date of 1/24/23, indicated, Secure catheter tubing with catheter securement device. Review of the facility policy Catheter: Urinary Care Of, last reviewed on 1/3/24, with a previous review date of 1/24/23, indicated that catheters are to be inspected for leakage. Catheters are to be secured and kept below the level of the resident's bladder. Catheters are to be changed as ordered and the physician is to be notified of any abnormal findings. Review of the clinical record indicated Resident R64 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/15/24, included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), hemiplegia (paralysis on one side of the body), and achondroplasia (short-limbed dwarfism). Review of Section H: Bladder and Bowel indicated Resident R64 has an indwelling catheter. Review of Resident R64's plan of care initiated on 5/24/24, indicated for the facility to ensure Resident R64 has a foley catheter securement device in place. Review of Resident R64's plan of care revised on 7/25/24, indicated Resident R64 has a suprapubic catheter, with interventions for catheter care twice daily and to ensure catheter securement device is in place. Review of Resident R64's physician's order history revealed the following: -5/24/24 through 7/24/24: Ensure Foley catheter securement device is in place every shift. -6/16/23 through 7/24/24: Indwelling catheter 16FR (16 French, catheter tubing size) with 10cc (cubic centimeters, equal to milliliters) balloon; to bedside, straight drainage for obstructive uropathy. -6/16/23 through 7/24/24: Change indwelling catheter monthly, and/or when occluded or leaking as needed AND every night shift starting on the 23rd and ending on the 23rd every month. -7/24/24: Change suprapubic catheter monthly and/or when occluded or leaking as needed AND every night shift starting on the 23rd and ending on the 23rd every month. -7/24/24: Ensure Suprapubic Catheter Securement Device is in place. every shift. Review of Resident R64's Documentation Survey Report (monthly record of nurse aide care) for the task of ensure foley catheter securement device is in place for May 2024 revealed this task was not documented as being done on the following shifts and dates: -Day Shift (0900-1500) 5/2, 5/3, 5/6, 5/15, 5/26, 5/26, 5/31. -Evening Shift (1500-2300) 5/2, 5/8, 5/10, 5/11, 5/17, 5/18, 5/19/ 5/20, 5/21, 5/22, 5/23, 5/25, 5/28, 5/31. -Night Shift (2300-0700) 5/5, 5/9, 5/11, 5/13, 5/19/, 5/28, 5/29. Review of a progress note written by Registered Nurse (RN) Employee E32 dated 5/24/24, at 4:30 a.m. indicated, Foley catheter changed, 18&10 (18 French, 10 cc balloon), this AM by this RN without issue. No urine return on insertion, but staff to monitor to ensure placement. The resident had no complaints or pain during insertion or after. Review of a progress note written by Licensed Practical Nurse (LPN)dated 5/24/24, at 9:00 a.m. indicated, when doing AM care CNA (NA, nurse aide) noted resident has a split in his penis. Review of a progress note dated 5/24/24, at 6:36 p.m. indicated, penis is injured from his Foley, tubing secured with clasp to prevent further injury. Review of a progress note dated 5/31/24, at 3:42 a.m. indicated, resident returned from urology f/u (follow-up) with new recommendation for suprapubic catheter (SPC) related to penile tear from Foley. Review of a progress note dated 6/11/24, at 10:44 p.m. indicated, Foley replaced by this RN with a 16 and 30 (16 French, 30 cc balloon). The previous foley fell out while the resident was being turned and changed. No trauma, swelling, or pain noted. Insertion done without issue or any complaints, positive for urine return. Staff to monitor. Tubing was clipped in a secure position to prevent injury. Review of a progress note dated 7/11/24, at 3:38 p.m. indicated Resident R64 returned from having a suprapubic catheter placed. Review of a progress note dated 7/15/24, at 3:50 p.m. indicated, urology called r/t urine leaking around spc. Review of a progress note dated 7/24/24, at 4:27 p.m. indicated, resident's urinary drainage bag noted to be empty, attempted to flush supra pubic catheter and could not. reinserted new supra pubic catheter and tip of catheter was coming out penis. Urology office called and said catheter was probably just being advanced too much, said to attempt to reinsert catheter and if could not be reinserted in facility resident would need to go to ER, reinserted catheter with no difficulty. when trying to flush catheter, flush was noted to be coming out the tip of penis and around supra pubic insertion site. Review of a urology consultation note dated 7/25/24, indicated, [Urologist] put in 20 fr (20 French) suprapubic tube 7/11/24. SNF (skilled nursing facility) took it upon themselves to change it earlier this week because of leakage and they put it through and through his urethra. Review of Resident R64's progress notes from 5/11/24, failed to include any progress notes that indicated bleeding, erosion, or trauma to Resident R64's penis until 5/24/24. During an interview on 8/19/24, at 11:30 a.m. Resident reported having an indwelling catheter for several years and that he has had issues with the catheter over the past few months. During an interview on 8/23/24, at 10:00 a.m. RN Employee E32 reviewed the progress note dated 5/24/24, at 04:30 a.m. and provided additional details of the care provided to Resident R64. RN Employee E32 reported that Resident R64 had been seen as the foley catheter had become dislodged. RN Employee E32 confirmed that foley catheter did not have a catheter securement device in place. RN Employee E32 noticed a small laceration to the penis of Resident R64. RN Employee E32 confirmed this was not observed during prior times when RN Employee E32 provided care to Resident R64. RN Employee E32 confirmed that she replaced the foley catheter with a size 18 French 10 cc balloon since the size 16 French dislodged, instead of the physician ordered 16 French with 10 cc balloon. RN Employee E32 stated supplies are not always available, and this may have influenced her decision in using the larger catheter size. During an interview on 8/23/24, at 10:15 a.m. LPN Employee E33 reviewed the progress note dated 5/24/24, at 09:00 a.m. and provided additional details of the care provided to Resident R64. LPN Employee E33 stated she was informed by the nurse aide that Resident R64 had a split in his penis. LPN Employee E33 documented the assessment of the resident and notified the doctor who gave a verbal order for follow up with urology and LPN Employee E33 noted Foley Securement Device placed on resident and that Resident R64 is scheduled with urology for 5/31/24. LPN Employee E33 stated during the interview the penis is split and that this patient's urinary catheter care, before and after the injury, has been a learning experience. During an interview on 8/23/24, at approximately 10:30 a.m. the Director of Nursing confirmed no progress notes indicated penile trauma prior to 5/24/24, confirmed that a larger size than ordered catheter was placed in Resident R64, documented as being placed less than five hours prior to the penile trauma being noted, confirmed that when Resident R64 was rolled, his catheter tubing was attached to the mattress/linen rather than Resident R64's legs causing the tubing to dislodge when Resident R64 was rolled, and confirmed that on 7/24/24, Resident R64's suprapubic catheter was advanced far enough to extend through Resident R64's penis. Review of clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included psychosis, lung disease, diabetes, obstructive and reflux uropathy (disease when urine cannot flow through ureter, bladder or urethra due to some type of obstruction and can cause urine to flow backwards), urinary retention and history of beast cancer. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R2's physician orders indicated change suprapubic catheter every night shift every 30 days for catheter care. The order start date identified as 3/26/24. Review of Resident R2's TAR's (Treatment Administration Record) dated from April 2024, through July 2024, did not include documentation that Resident R2's suprapubic catheter had been changed and nursing progress notes dated through the time identified included one statement that on June 25, 2024 Resident R2 had stated that she did not want the catheter changed as it had been done a couple days before, which had not been documented. Documentation did not indicate that staff had made an attempt to re-visit the change of the catheter with Resident R2 on any date since the placement of the suprapubic catheter in March 2024. During an interview on 8/23/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that residents with suprapubic urinary catheters received appropriate treatment and services consistent with professional standards during catheter care by monitoring placement and skin, changing the catheters and providing care, resulting in actual harm as evidenced by penile split and traumatic insertion and removal for one of three residents and failure to change a urinary catheter every 30 days as ordered for one of three residents. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility documentation and staff interviews, the facility failed to provide adequate supervision to prevent a fall with injuries for one of six residents reviewed (Resident R124), resulting in harm with a fracture of the left radius and ulna fracture (wrist fracture) that resulted in a transfer to the hospital. Findings include: Review of facility policy Accidents/Incidents dated 1/1/2021 & 8/31/2021, indicated that An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident. Review of Resident R124's clinical record Admission Record Report indicated that the resident was admitted to the facility on [DATE], and a re-admitted [DATE], with diagnosis of [CONDITION(S)] (irregular and often rapid heart rate), muscle weakness (decrease in the strength in one or more muscles), unspecified signs and symptoms involving cognitive functions and awareness( lack of awareness of, or refusal or failure to deal with or recognize that one has a mental or physical disorder), and history of falling (increased chance of conditions that result in falls. Increased susceptibility to falling that may cause physical harm). Review of the entry MDS (Minimum Data Set - a periodic assessment of resident needs) dated 6/17/21, indicated that Resident R124 cognitive skills for daily skill making were severely impaired and Section G Activities of Daily Living indicated Resident R124 is 3/3 ( resident is an extensive assist for all care needs). Review of Resident R124's physician orders with a start date of 7/30/21, active through 8/23/21, indicated that Resident 1:1 (one person to one resident) ratio continuously dx secondary to multiple falls. Review of facility documents daily staffing sheet 8/21/21 and 8/22/21, indicated Resident R124 was scheduled for 1:1 Review of facility documentation General Progress Note dated 8/22/21, indicated Resident R124 was found on floor on stomach bedside bed. Review of facility documentation Witness Interview Record dated 8/22/21, Nurse Aide (NA) Employee E8 indicated that Resident R124 was found on the floor in the room lying on his/her stomach, that no one else was present. Further review indicated NA Employee E8 asked NA Employee E9 to watch resident R124 while they took a break. Review of facility documentation Witness Interview Record dated 8/22/21, indicated NA Employee E9 indicated that last I seen Resident R124 was sleeping in bed. Additional comments indicated NA Employee E9 states Resident R124 was asleep and (NA Employee E9) got up and left the room. On 8/23/21, additional statements obtained from NA Employee E8 included the following: I had to leave the room quickly, I started about lunch time the trays were up I told NA Employee E9 (that I had to leave) I left the room before NA Employee E9 came in - NA Employee E9 was about 3 doors away from Resident R124 room. I was out of the room for about 10-15 minutes, at most , when I returned I found Resident R124 on the floor. Resident R124 was on the door side of the bed, more towards the foot of the bed and was lying on stomach. Resident R124 wasn't moving or making any noise. I yelled for the nurse to come into the room. On 8/23/21, additional statements obtained from NA Employee E9 that included the following: at about 12:10 pm NA Employee E8 asked me to keep an eye on Resident R124 while NA Employee E8 was out of the room. Another resident asked for ice, I went to get the ice, Resident R124 fell during this time. During an interview on 8/30/21, at 1:57 p.m. NA Employee E9 confirmed that NA Employee E8 asked NA Employee E9 to watch Resident R124, and NA Employee E9 stepped out of the room to get ice, and during that time Resident R124 fell . Review of the Emergency Department Report Expanded Results Detail - findings, Impressions and Diagnosis dated 8/22/21, indicated There is a displaced comminuted impacted intra-articular fracture of the distal radial metaphysis (. There is about 2cm dorsal displacement 9 mm impaction and 10 mm lateral displacement. There is dorsal displacement of a fracture of the ulnar styloid, with mild overriding. Impression: Fractures of the distal left radial metaphysis and ulnar styloid ( group of fractures that occur at the distal radius and are the dominant fracture type at the wrist and the bony part of your wrist next to your pinky finger is the end of the ulna, when you break that part of the wrist, it's called an ulnar styloid fracture). Diagnosis: Left radius and ulna fracture. During an interview on 8/30/21, at 4:37 p.m. Nursing Home Administrator and Director of Nursing confirmed that Resident R124 was to have a 1:1 with staff, that NA Employee E9 left the Resident unattended and unsupervised and during that time Resident R124 fell out of bed and was sent to the hospital and diagnosed with a fracture of the left radius and ulna fracture (wrist fracture) resulting in harm to Resident R124. The facility failed to provide adequate supervision for one of six residents reviewed (R124), resulting in harm with a left radius and ulna fracture (wrist fracture). 28. Pa. Code 201.14(a) Responsibility of Licensee. 28. Pa. Code 201.18(b)(1) Management. Previously cited 7/16/20 28. Pa Code 201.18 e(1) Management. 28. Pa. Code 201.29(d) Resident Rights. 28. Pa. Code 211.10(d)Resident care policies. Previously cited 3/18/21 28. Pa. Code 211.10 c Resident care policies. 28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and clinical records and facility documentation, observations and staff interviews, it was determined that the facility failed to make certain that one of three residents was free from abuse and neglect, which resulted in actual harm (Resident R157) and failed to ensure that one of three residents was free from abuse (Resident R130). The findings include: Review of the facility policy Abuse Prohibition last reviewed 5/29/19, previous review date of 2/28/18, indicated that the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the patient's medical symptoms. Review of the facility policy Dementia: care of patient last reviewed on 5/29/19, indicated that the expected approach follows a systematic process which is tailored to each individuals needs and staff are to monitor conditions for safety to self and/or others. The Admission Record Report indicated that Resident R157 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 7/12/19, indicated Resident R157 was alert, oriented and able to make decisions, required the extensive assistance of two or more persons with transfers, bed mobility and personal hygiene and that the resident had range of motion impairment of the upper and lower extremities on both sides. The care plan dated 7/5/19, indicated that Resident R157 is dependent on staff assistance for activities of daily living (ADL-which included bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting). The care plan indicated that Resident R157 required extensive assist of two for transfers using a pivot transfer. A physician's order dated 7/5/19, indicated that Resident R157 required the assist of two (staff) with pivot transfers. The physical therapy evaluation and plan of treatment forms dated 7/8/19, identified Resident R157 with decrease in functional mobility (movement), decrease in strength, decreased coordination, falls/fall risk, reduced dynamic (while in motion) and static (stationary) balance and reduced sensation. The occupational therapy evaluation and plan of treatment forms dated 7/8/19 identified Resident R157 with impaired ADL performance, impaired balance, impaired functional mobility, impaired joint integrity and impaired positioning. A nurse's note dated 7/15/19, at 2:27 p.m. indicated CNA (Nursing Assistant) alerted nurse that patient had a fall to the floor from sitting on side of bed. Upon assessment patient unresponsive for approximately three minutes, then did open eyes and began answering questions but slowly. Patient pupils responsive but slow. Patient complained of pain in right shoulder and leg, back and head. Patient noted to have a small lump on left side of head with minor bleeding noted, pressure applied. Skin tears also noted to left elbow and right knee. Areas cleansed and treatments applied. Patient was not moved by staff. EMS arrived and moved patient from floor to stretcher. Patient transferred to hospital. Facility RMS Event Summary Report (incident investigation) indicated that the incident occurred 7/15/19, at 8:00 a.m. A physician's order dated 7/15/19, at 8:15 a.m. indicated transfer Resident R157 to emergency room for evaluation via ambulance. A review of the acute care records dated 7/15/19, at 11:57 a.m. indicated that as a result of the fall, Resident R157 was diagnosed with [REDACTED]. A review of the facility investigation of Resident R157's 7/15/19, fall from the bed indicated that the NA sat the resident on side/edge of bed in preparing for transfer. NA left resident sitting on the side/edge of the bed when she turned around to clean off resident's wheelchair that was next to the bed. Resident with poor trunk control, lost her balance and fell to the floor. NA, Employee E25, did not follow the resident's care plan for two staff assistance as required for transfers. In a handwritten statement signed by NA, Employee E25, and dated on 7/15/19, that after topping her (putting a shirt on Resident R157) she was just sitting on the edge of the bed. I was just about to get assistance to transfer her and she (Resident R157) stated that her wheelchair pad was dirty and asked me to clean it. I used a cloth to wipe her wheelchair. At this point the resident fell forward. During an interview on 7/25/19, at 8:00 a.m. the Director of Nursing confirmed that the facility failed to make certain that Resident R157 was free from neglect during care which resulted in actual harm to the resident. The facility failed to make certain that Resident R157 was protected from neglect while providing personal hygiene resulting in actual harm. Review of the clinical record indicated that Resident R130 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE], indicated the [DIAGNOSES REDACTED]. During an observation on 7/21/19, at 8:45 a.m. Resident R10 appeared very aggressive and yelling and cussing at all the other ten residents in lounge. Facility staff were not in the area. Resident R130 was seated at a table with two other residents. Resident R10 came behind Resident R130 and forcefully grabbed Resident R130's left neck and pulled her hair. Resident R130 yelled you're hurting me! Staff did not respond until the SA called for them and waved to a NA coming down the hall. The NA and the LPN separated the two residents. Resident R130 required a treatment to the area which was very beefy red and appeared to be bleeding. Resident R130 was very tearful and upset. During an interview on 7/21/19, at 9:00 a.m. the Licensed Practical Nurse(LPN) Employee E16 confirmed that the facility failed to prevent resident to resident abuse due to residents not being monitored by any staff in the lounge. 42 CFR 483.12(a)(1) Free from Abuse and Neglect. 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 6/12/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/17/17, 6/12/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 7/17/17, 6/12/18. 28 Pa. Code 201.29(a)(d)(j) Resident rights. Previously cited 7/17/17, 6/12/18. 28 Pa. Code 201.29(c) Resident rights. Previously cited 7/17/17, 6/12/18. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on the facility policy, clinical record review, observations and staff interview, it was determined that the facility failed to assess a resident's ability to safely use a microwave, which resulted in second [MEDICAL CONDITION] Resident R99's thighs thus resulting in harm for one of six residents reviewed (Resident R99). Findings include: Review of a clinical record indicated that Resident R99 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a progress note dated 2/19/18, at 1:34 p.m. indicated that a change in resident's condition had occurred and documentation indicated that Resident R99 [MEDICAL CONDITION] the bilateral inner thighs from dropping her hot soup. A review of the facility incident report dated for 2/19/18, at 1:15 p.m. documentation indicated that Resident R99 was removing her soup from her personal microwave and soup spilled out of the side of the bowl, causing her to drop the bowl on her inner thighs. The areas were assessed as right inner thigh redness of 18 cm (centimeters) x 10 cm. The corrective action documented on the incident report indicated that physical and occupational therapies were to assess the resident for the ability to use her microwave safely. During an interview on 6/7/18, at 2:05 p.m. the Director of Nursing indicated that the facility had no policy for personal microwave use. A review of Resident R99's Minimum Data Set assessment (MDS-an assessment to evaluate the resident's mental and physical abilities) dated 2/1/18, indicated that the resident required physical help to bathe and dress with lower extremity weakness and required a wheelchair for mobility. The resident had a Brief Interview for Mental Status (BIMS-a tool to assess cognitive function) score of 15 (a score of 13-15 indicates that the resident is cognitively intact). During an interview and observation on 6/8/18, at 9:15 a.m. Resident R99 still had a microwave in her room. Resident R99 stated she was getting soup from microwave and the bowl tipped and spilled on her hand and she dropped the bowl onto her lap. Resident stated she was moving to an assisted living arrangement and was heading to therapy for last session, since she had to stop while her burn healed. Resident R99 stated she had gone to see a plastic surgeon for the burn. During an interview on 6/8/18, at 12:45 p.m. the Assistant Director of Nursing Employee E2, confirmed that a risk assessment and occupational screening for use of the microwave had not been completed for any of the three residents with personal microwaves in their rooms, until after Resident R99 was burned. Resident 99's evaluation was not able to be completed due to her pain from the burns. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/10/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/17/17, 6/10/16. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 7/17/17, 6/10/16. 28 Pa. Code 201.29(a)(c) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 7/17/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 7/17/17, 6/10/16. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/17/17.