Every finding on record at Bryn Mawr Village

Based on review of facility policy, facility documentation, clinical records, and staff interview it was determined the facility failed to ensure the resident environment remained free of accident hazards for one of 12 residents reviewed (Resident R47). This failure resulted in actual harm to Resident R47 who spilled a hot liquid on his/her thigh resulting in a burn. This deficiency was identified as past non-compliance.Findings Include: Review of facility policy Assisting the Resident with In-Room Meals revised December 2013 revealed staff should check that hot foods are hot (but not scalding temperature). Review of Resident R47's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 20, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (lack of sufficient nutrients in the body), muscle wasting, and muscle weakness.Continued review of Resident R47's comprehensive MDS dated [DATE], revealed the resident was cognitively intact and required setup or clean-up assistance with eating (helper sets up or cleans up).Review of Resident R47's clinical record revealed a nursing note dated October 3, 2025, indicating the nurse aide responded to Resident R47's room after hearing resident call out for help. Upon entry, it was observed that a bowl of chicken broth from the dinner tray had spilled onto Resident R47's lap.Review of facility documentation titled Burn incident report dated October 3, 2025, revealed the resident's soiled clothing was removed and the area was cleansed with cold water and cold compress was applied. A nursing assessment revealed a raised area to the left inner thigh, measuring approximately 30 centimeters (cm) (length) by 8 cm (width) in size. Resident R47 reported tenderness to touch.Review of facility documentation revealed a statement obtained on October 3, 2025, from Resident R47, which indicated that while attempting to hold his/her cup of soup he/she dropped it because it was too hot. Resident R47 reported that he/she yelled out and the nurse responded/assisted.Review of facility documentation revealed a written statement dated October 3, 2025, by nurse aide, Employee E10, that indicated the employee gave Resident R47 a bowl of soup and instructed the resident that the second bowl of soup on the meal tray was too hot and to wait to eat it. Nurse aide, Employee E10, reportedly left the room to assist other residents when he/she heard the resident cry out. Nurse aide, Employee E10, ran back to the room and Resident R47 told the nurse aide he/she picked up the soup that was identified as being too hot and it subsequently spilled onto Resident R47's thigh.Interview on February 11, 2026, at 12:37 p.m. with nurse aide, Employee E10, revealed two bowls of chicken broth were requested to be sent with Resident R47's dinner tray on October 3, 2025. Resident R47 was reportedly positioned upright in bed with the overbed table set-up over Resident R47's lap.Continued interview on February 11, 2026, at 12:37 p.m. with Nurse aide, Employee E10, revealed he/she delivered Resident 47 his/her dinner tray [which contained two bowls of chicken broth] and removed the lid of one bowl of soup, pushing it closer to the resident. Interview conducted on February 11, 2026, at 12:37 p.m. with Nurse aide, Employee E10, revealed he/she only partially lifted the lid off the second bowl of soup and instructed Resident R47 to wait to eat it, as the soup bowel was identified to be hotter of the two bowls. Nurse aide, Employee E10, described the second bowl of soup to be hotter due to the condensation/steam observed beneath the lid. Just after nurse aide, Employee E10, left the room he/she heard Resident R47 cry out and promptly turned around to assist the resident. Review of Resident R47's clinical record revealed a nursing note dated October 4, 2025, indicating the area was identified as a superficial burn and noted to be blistered and red.Review of Resident R47's clinical record including a nursing note dated October 6, 2025, revealed the area was observed to be very reddened and blistering. Warm to touch, and painful.Review of Resident R47's wound care consult dated October 8, 2025, revealed the resident was seen for an initial consultation for wound care services for burn to the left thigh. The wound type was described as a burn with partial-thickness depth exposure. The wound size was described as a clustered wound and measured 22 cm (length) x 40.4 cm (width) x 0.1 cm (depth). Resident R47 was noted wild mild transient pain during the wound assessment.On October 3, 2025, following the incident, the facility immediately implemented the following corrective action:Resident R47 immediately assisted the resident by removing soiled clothing and cooling the affected area. A nursing assessment was completed and the physician was notified. Treatment orders were implemented, including prescribed topical treatment and dressings. The resident's family was notified, and the resident was monitored for changes in condition until healing was observed.All residents were reviewed for potential risk related to hot liquids. A hot liquid safety screening was completed for residents receiving hot beverages or hot foods. Residents identified with potential risk now have appropriate supervision, assistance, or safety interventions in place per individualized care plans.The facility updated the residents care plan to include supervision and safety precautions when hot liquids are served. Staff must remove or loosen lids prior to tray delivery to ensure safe placement of hot items. Education was provided to nursing, dietary, and nurse aide staff regarding hot liquid safety, tray delivery procedures, and monitoring requirements for residents consuming hot food or beverages.The Director of Nursing or designee will audit tray delivery and hot liquid safety practices weekly for four weeks, the monthly for three months to ensure compliance. Care plans and hot liquid risk screenings will be reviewed for accuracy. Findings will be reported through Quality Assurance Program (QAPI) and additional education provided if concerns are identified.Review of facility documentation revealed the facility implemented a revised Hot Liquid Safety Policy and Procedure effective October 6, 2025, which included safe temperature standards, identification of high-risk residents, and service and assistance requirements.Review of facility documentation confirmed a full house audit was conducted to ensure all residents had a hot liquid safety assessment completed. Resident care plans were subsequently updated to reflect hot liquid safety interventions and supervision needs.Review of staff education and staff interviews revealed dietary staff were educated on safe food handling, monitoring temperatures before meal service, and review and demonstration on thermometer calibration.Continued review of staff education and staff interviews revealed education was provided to on removing the lids of all hot containers before fully serving. If residents request the food or drink to be heated the items must go to dietary to ensure proper temperature.Review of facility documentation confirmed weekly, and monthly tray delivery and hot liquid safety audits were conducted to ensure compliance. Audits included observance of a hot liquid, set-up assistance of item, placement, supervision, was the care plan followed and were any issues identified.This deficiency was identified as past non-compliance. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to discuss the risks/benefits in advance for newly admitted resident for two of five resident records reviewed (Residents R1, and R23).Findings include:A review of the clinical record for Resident R1 revealed an admission date of July 21, 2025, with diagnosis of acute respiratory failure with hypoxia, parkinsonism, shortness of breath, heart failure, type 2 diabetes mellitus, depression, hypoxemia and acute kidney failure. Further review of the clinical record indicated physician orders for Resident R1 that included the following medications: insulin glargine subcutaneous solution (100 units/mL), with instructions to inject 20 units in the evening for diabetes; pramipexole dihydrochloride 0.5 mg orally at bedtime for Parkinson's disease; Eliquis 5 mg orally twice daily for atrial flutter; nifedipine extended-release 30 mg orally once daily for hypertension; and metoprolol succinate extended-release 25 mg orally once daily for congestive heart failure (CHF). Continued review of Resident 1's clinical record revealed no documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the medication, including side effects and other adverse reactions. An interview conducted on February 12, 2026, at 11:08 a.m. with the Administrator, Employee E1, Director of Nursing (DON), Employee E2, and Regional Nurse, Employee E3, confirmed that a review of the risks and benefits of Resident R1's medication and treatment was not conducted in advance with the resident or his/her representative at the time of admission on [DATE]. The review was subsequently conducted on September 18, 2025. A review of the clinical record for Resident R23 revealed an admission date of January 07, 2026, with diagnosis cognitive communication deficit, major depressive disorder and anemia. Further review of the clinical record indicated physician orders for Resident R23 that included the following medications: Lansoprazole 30 (milligrams) mg, Acetaminophen Tablet 325 mg, Fleet Enema 7-19 GM/118ML (Sodium Phosphates) Dulcolax Suppository (Bisacodyl), Mirtazapine Oral Tablet 7.5 MG (Mirtazapine).Continued review of Resident 23's clinical record revealed no documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the medication, including side effects and other adverse reactions. An interview conducted on February 12, 2026, at 12:45pm with the Administrator, Employee E1, Director of Nursing (DON), Employee E2, and Regional Nurse, Employee E3, confirmed that a review of the risks and benefits of Resident R23's medication and treatment was not conducted in advance with the resident or his/her representative at the time of admission on [DATE]. The review was subsequently conducted on September 18, 2025. 28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 201.29(a) Resident Rights.

Based on review of facility policy and review of clinical records, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan for two of three newly admitted residents reviewed (Resident R38, and R45).Findings:A review of the facility policy titled Care Plans-Baseline, last revised in March 2022, revealed that, a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forth-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care pf the resident that meet professional standards of quality care and must include a minimum healthcare information necessary to properly care for the resident including, but not limited to the following; initial goals based on admission orders and discussion with there resident/representative, physician orders, dietary orders, therapy services, social services, and PASSSAR recommendation, if applicable. Under bulletin 4 it further states, The resident and/or representative are provided a written summary of the baseline care plan in a language that the resident/representative can understand. On February 11, 2026, at 1:55 p.m., the Director of Nursing (DON), Employee E2, confirmed that residents or their representatives do not automatically receive a copy of the baseline care plan unless they specifically request one. On February 11, 2026, at 1:59 p.m., an interview was conducted with the Social Services Director, Employee E4, who also confirmed that a copy of the baseline care plan is provided only upon request. On February 11, 2026, at 2:11 p.m., an interview was conducted with Resident R38, who is alert and oriented. Resident R38 reported that she was not offered a copy of her baseline care plan upon admission to the facility on January 2, 2026. Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness. Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that revealed resident was a new admission with the following diagnosis of pain management. Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain. Review of Resident R45's clinical record revealed no documented evidence a baseline care plan was developed and implemented with individualized goals and interventions for pain management. Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness. Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that revealed resident was a new admission with the following diagnosis of pain management. Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain. Review of Resident R45's clinical record revealed no documented evidence a baseline care plan was developed and implemented with individualized goals and interventions for pain management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, review of clinical record, and resident interview, it was determined that the facility failed to implement interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of 12 residents reviewed (Resident R19).Findings Include:Review of facility policy Weight Assessment and Intervention revised February 2021 revealed resident weight will be measured on admission and weekly for four weeks thereafter. Any weight change of 5% or more since the last weight assessment will be addressed by the Registered Dietitian.Review of Resident R19's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 31, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of cancer, diabetes mellitus, muscle wasting, and dysphagia (difficulty swallowing).Continued review of Resident R19's comprehensive MDS dated [DATE], revealed the resident had signs and symptoms of swallowing disorder such as holding food in mouth/cheeks and complaints of difficulty or pain with swallowing.Review of Resident R19's clinical record revealed a nutrition assessment dated [DATE], that Resident R19 was assessed at a weight of 149 pounds [obtained May 25, 2025] and was deemed at nutrition risk related to poor intake.Further review of Resident R19's clinical record revealed a nutrition note dated May 28, 2025, that Resident R19 requested more Ensure (oral nutritional supplement). Further review of the nutrition note revealed the Registered Dietitian recommended Ensure nutritional supplement three times per day to aid in weight maintenance.Review of Resident R19's clinical record revealed no documented evidence the nutritional supplement was provided per the dietitian recommendations. Review of Resident R19's weight summary revealed a documented weight of 120.5 pounds on June 10, 2025, reflecting a 19% weight loss since May 25, 2025.Review of Resident R19's clinical record revealed a nutrition note dated June 13, 2025, that Resident R19 sustained a 19% weight loss, was reassessed with a weight of 120.5 pounds and deemed underweight for range of age. Reassessment included use of Ensure nutrition supplement three times per day. Resident R19 was identified as at risk for malnutrition related to poor intakes and low body mass index (BMI).Review of Resident R19's clinical record revealed no documented evidence the nutritional supplement Ensure three times per day was provided per recommendations.28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations, review facility policies and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas for one of two nursing units observed (CE Unit).Findings include:On February 9, 2026, at 10:45 a.m., an observation conducted in Room CE40 revealed that Resident R35 was seated in (her/his) wheelchair. The resident's bed was without sheets, a blanket, or a pillowcase. Two clear trash bags were observed next to Resident R35. One bag contained soiled linens, and the other contained a soiled brief and used gloves. The resident's toilet was observed to be soiled with brown feces on the interior surfaces.Additionally, a wound VAC machine was also observed on the floor next to the window in Resident R35's room. According to the resident's family member, the wound VAC machine was no longer in use and had been left on the floor for several days. The family member stated that Resident R35 was no longer receiving treatment with the device.On February 9, 2026, at 10:58 a.m., the above observations were confirmed by Registered Nurse (RN), Employee E7. Employee E7 removed the two trash bags from the room and placed them in the designated soiled utility area. Further observation revealed that the toilet was clogged with feces. Employee E7 attempted to clear the obstruction; however, the water level in the toilet began to rise and did not drain appropriately. On February 10, 2026, at 9:39 a.m., an observation was conducted in Room CE45. Resident R6 was observed lying in bed receiving enteral feeding. The wall behind the bed, bedside dresser, bed rails, floor, and enteral feeding pole were observed to have dried brown and yellow feeding spills and drips present.This observation was confirmed the same day at 9:45 a.m. by the Regional Nurse, Employee E3.28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the State Survey Agency of an allegation of verbal abuse within 24 hours for one of 12 residents reviewed. (Resident R 41) Findings include: Review of Resident 41's Minimum Data Set (MDS- assessment of residents care needs) revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact and able to accurately report concerns. Continue review of Resident R41's clinical record revealed that the resident's diagnoses include Type 2 Diabetes Mellitus (failure of the body to produce insulin) without complications, Dysphagia (difficulty swallowing), Muscle weakness, and other abnormalities of gait and mobility.Resident R41 revealed during interview conduct on February 9, 2026, at 12:19 PM that (he/she) was verbally abuse by staff.Facility Administrator (NHA) and Director of Nursing (DON) were notified of the allegation of verbal abuse presented by Resident #41 on February 9, 2026 at 1:46 PM.Review of the Pennsylvania Electronic State Reporting System revealed that it was not until February 11, 2026, that the facility submitted a report regarding verbal abuse involving Resident R41, which was not within 24 hours of the allegation, as required. 28 Pa Code 201.18(b)(3) Management 28 PA. Code 211.12(c) Nursing services

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of twelve residents reviewed (Residents R31 and R6).Findings:A review of the clinical record for Resident R31 revealed an admission date of December 29, 2025, with a diagnosis of periprosthetic fracture around the internal prosthetic left hip joint.Nursing progress notes dated January 7, 2026, at 2:56 p.m., indicated that the resident was observed to have redness to her right heel during the shift. No visible open area was present at that time. The resident denied pain and itching. An order was entered for skin preparation to the right heel daily. A voicemail message was left for the physician. The resident is identified as her own responsible party.A review of the wound tracking sheet documented that on January 14, 2026, the resident was noted to have a right heel deep tissue pressure injury (DTPI) measuring 3.5 centimeters (cm) by 3.8 cm.A physician order dated December 29, 2025, indicated, Off-load bilateral heels as tolerated.A review of the comprehensive care plan dated December 29, 2025, did not reflect that a comprehensive care plan was developed to address the intervention to off-load bilateral heels as tolerated. Documentation indicated that the comprehensive care plan addressing this intervention was not developed until January 20, 2026.On February 11, 2026, at 2:40 p.m., the Regional Nurse, Employee E4, confirmed that a comprehensive care plan for the off-loading of bilateral heels was not developed until January 20, 2026. A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension.On February 9, 2026, at 11:03 a.m., an observation with Registered Nurse Employee E7 confirmed that Resident R6 was receiving oxygen therapy at 1.5 liters per minute.On February 12, 2026, at 2:02 p.m., a review of the clinical record with the Director of Nursing (DON), Employee E2, confirmed that Resident R6 did not have a comprehensive care plan related to oxygen therapy in place prior to its last revision on January 19, 2026.28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12(d) Nursing services

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of five residents observed during medication administration pass (Resident R31).Findings include:A review of the facility policy titled Administering Medication Revised April 2019, revealed medication are administered in a safe and timely manner and as prescribed. It further indicated under bulletin #4. Medications are administered in accordance with prescribed orders, including any required time frame. A review of the clinical record for Resident R31 revealed an admission date of December 29, 2025, with diagnoses including asthma and chronic obstructive pulmonary disease (COPD).A review of the physician's order dated December 29, 2025, indicated that Resident R31 was prescribed Symbicort Inhalation Aerosol 160-4.5 mcg/act (budesonide-formoterol fumarate dihydrate), with instructions to inhale two puffs orally twice daily for COPD.On February 9, 2026, at 11:48 a.m. Resident R31 reported that (she/he) did nor received (her/his) inhalation aerosol puffs since last Friday, February 6, 2026, facility has notified (her/him) that they do not have the inhaler medication available.A progress note dated February 9, 2026, at 5:00 p.m., documented by Licensed Nurse (LN) Employee E11, stating: Symbicort Inhalation Aerosol 160-4.5 mcg/act, inhale 2 puffs orally twice daily for COPD. Med not available; on order.On February 10, 2026, at 9:56 a.m., an observation was conducted with Licensed Nurse, Employee E7. Employee E7 reported that the inhalation aerosol treatment had been administered that morning and documented as given for Resident R31. When asked to produce the inhaler, Employee E7 was unable to locate the inhaler in the medication cart. Employee E7 then stated that she would strike through the medication administration entry, as the treatment had not been administered.On February 10, 2026, at 10:12 a.m. an interview was conducted with Director of Nursing who also confirmed that Symbicort Inhalation Aerosol 160-4.5 mcg/act was not available to the resident R31.A progress note dated February 9, 2026, at 12:50 p.m., was documented by Employee E7 stating: Medication (inhaler) was not available for the morning medication pass. The medication was struck out and reordered, awaiting pharmacy delivery. The physician was notified, and the medication is on hold until delivery.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper nail care for one of the 12 residents reviewed (Residents R6). Findings:A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).Review of Resident R6's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted periodically to plan resident care) dated November 18, 2025, revealed that Resident R6 was totally dependent on staff for activities of daily living to include hygiene, bed mobility, transfers, toilet use and showers.Continued review of the MDS revealed a Brief Interview for Mental Status (BIMS) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment.On February 10, 2026, at 10:24 a.m., a telephone interview was conducted with the resident's representative, who reported that Resident R6's nails had been long and dirty in the past. The representative further stated that Resident R6 uses (his/her) left hand to scratch (his/her) neck and that (his/her) nails should be kept short.On February 11, 2026, at 1:50 p.m., an observation was conducted with the Director of Nursing (DON), Employee E2. The observation revealed that the resident had long fingernails on both hands, and the fingernails on the left hand were noted to be dirty.28 Pa. Code 211.12 (d)(1) (5) Nursing Services

Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to implement preventative care for a resident at risk of alterations in skin integrity for one of 12 residents reviewed (Resident R49).Findings Include:Review of Resident R49's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.Continued review of Resident R49's MDS dated [DATE], revealed the resident was identified as at risk of developing pressure ulcers/injuries.Review of Resident R49's admission skin evaluation dated February 1, 2026, revealed the resident was assessed with erythema (superficial reddening of the skin) to his/her sacral area.Review of Resident R49's comprehensive care plan dated February 1, 2026, revealed the resident was at risk for alterations in skin integrity. Intervention dated February 1, 2026, revealed to use a pressure reduction device on bed/chair.Observations on February 9, 2026, at approximately 10:15 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained of discomfort on his/her buttock area and requested repositioning. Further observations revealed no cushion or pressure reduction device was on Resident R49's wheelchair seat.Interview on February 9, 2026, at approximately 10:20 a.m. with Licensed Nurse, Employee E6, confirmed Resident R49 did not have a cushion or pressure reduction device on the wheelchair seat. Licensed nurse, Employee E6, subsequently went on to collect and apply the wheelchair seat cushion for Resident R49. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1) Nursing services.

Based on observation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure enteral feedings were labeled in accordance with professional standards of practice, for one of one resident reviewed for tube feeding (Resident R6).Findings include:A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).A review of the physician's order for Resident R6, dated September 16, 2025, indicated an enteral feeding order as follows: Glucerna 1.2 at a rate of 85 mL/hour for 18 hours, for a total volume of 1530 mL. Feeding to be initiated at 4:00 p.m. and discontinued at 10:00 a.m. each day.On February 9, 2026, at 11:06 p.m., an observation was conducted with Licensed Nurse (LN) Employee E7. The observation revealed that Resident R6 was in bed receiving enteral feeding. The feeding bag was not labeled with the resident's name, date, or time of initiation. The bedside table contained multiple enteral feeding caps that were observed to be unsanitary. Additionally, the enteral feeding bottle was empty; however, per the physician's order, the feeding should have been discontinued at 10:00 a.m.28 Pa Code 211.10(c) Resident care policies28 Pa Code 211.12(d)(3)(5) Nursing services

Based on a review of clinical records, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one of one residents reviewed. (Resident R6).Findings include:A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by a blockage), muscle weakness, unspecified dementia, hemiplegia (paralysis of one side of the body), aphasia (impairment of communication), dysphagia (difficulty swallowing), and hypertension (high blood pressure).On February 9, 2026, at 11:03 a.m., an observation with Registered Nurse, Employee E7 confirmed that Resident R6 was receiving oxygen therapy at 1.5 liters per minute. The oxygen tubing was not labeled, and the filter behind the concentrator was dirty, with a layer of dust.On February 12, 2026, at 2:02 p.m., a review of the clinical file with the Director of Nursing (DON), Employee E2, confirmed that Resident R6 did not have a physician order for oxygen therapy.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to provide pain management consistent with a resident's assessed needs for one of 12 residents reviewed (Resident R45).Findings Include:Review of facility policy Pain - Clinical Protocol revealed with input from the resident, the physician and staff will establish goals of pain treatment.Review of Resident R45's Minimum Data Set (federally mandated resident assessment and care screening) dated November 15, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs), respiratory failure, and muscle weakness.Review of Resident R45's after visit summary from the hospital dated November 12, 2025, revealed oxycodone 10 milliliters (ml) solution was recommended as needed.Review of Resident R45's clinical record revealed a physician order dated November 13, 2025, to give oxycodone (opioid used to treat moderate to severe pain) oral solution 10 ml every 12 hours as needed for pain, and an order to give oxycodone oral tablet 5 milligrams (mg) every 6 hours as needed for severe pain.Review of Resident R45's clinical record revealed a nursing note dated November 13, 2025, that Resident R45 refused any Tylenol for pain and is waiting for his/her narcotics.Review of Resident R45's pain evaluation dated November 14, 2025, revealed the resident received both scheduled and as needed pain medication, and the resident reported frequent pain over the last five days. Per the pain evaluation dated November 14, 2025, Resident R45 was identified as at risk for pain.Review of Resident R45's medication administration record revealed on November 14, 2025, the resident complained of a pain level of 7 and the nurse subsequently provided the as needed (PRN) 5 mg oxycodone oral. Per the medication administration record, the effectiveness was noted as ineffective with a linked nursing note, dated November 14, 2025, that indicated the PRN administration of the oxycodone was ineffective and Resident R45 continued to be in pain.Continued review of Resident R45's clinical record revealed a progress note dated November 14, 2025, that the pharmacy was contacted regarding delivery of oxycodone oral solution. Per the nursing note, the pharmacist stated there was no script sent for the medication. The on-call physician was notified and phoned script into the pharmacy. It was confirmed with the pharmacy that the medication was going to be sent out that night [November 14, 2025].Review of Resident R45's clinical record revealed a nursing note dated November 14, 2025, that the resident complained of abdominal pain and discomfort further stating he/she was not pleased with pain regimen. Per the nursing note, the nurse explained to Resident R45 that the oral liquid solution of the oxycodone was unavailable and in the meantime oxycodone tablet form would need to be administered.Review of Resident R45's clinical record revealed a nursing note dated November 15, 2025, that the resident dialed 911 because he/she was unsatisfied with pain.Further review of Resident R45's clinical record revealed a nursing note dated November 16, 2025, that the resident returned from the hospital and requested to leave against medical advice.Review of Resident R45's medication administration record revealed Resident R45 never received the oxycodone oral solution per the hospital recommendations. Resident R45 continued to complain of pain and ineffectiveness of regimen.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy and review of clinical records it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of 12 residents reviewed. Findings Include:Review of facility policy Medication Shortages/Unavailable Medications revealed when medications are unavailable the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider.Continued review of facility policy Medication Shortages/Unavailable Medications revealed a medication shortage is noted the nurse should notify the pharmacy and determine the status of the order. If the next available delivery results in a delay or missed dose in the resident's medication regimen the nurse should retrieve the medication from the emergency stock or request an emergency/stat delivery from the pharmacy. If an emergency delivery/emergency stock is not feasible, the licensed nurse should contact the attending physician and order orders which may include holding the dose, use of alternative medication, or a change in order.Review of Resident R49's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.Review of Resident R49's clinical record revealed a physician order dated February 2, 2026, to administer carvedilol by mouth two times per day (scheduled for the morning and evening) for hypertension (high blood pressure).Review of Resident R49's medication administration record revealed from February 2, 2026, through February 6, 2026 (total of 10 doses) the carvedilol was omitted seven times and signed out with a code for other/see progress notes.Review of Resident R49's clinical record revealed nursing notes dated February 2, February 3, February 4, February 5, and February 6, 2026, that the facility was awaiting pharmacy or awaiting delivery of the carvedilol.Further review of Resident R49's clinical record revealed no documented evidence that the physician was made aware of the missed doses, that an alternate treatment was requested, or specific orders for monitoring while the medication was unavailable. Review of the clinical record revealed no documented evidence the licensed nurse determined the reason for unavailability, length of time medication is unavailable, and what efforts were attempted to obtain the medication.28 Pa. Code 211.9 (a)(1) Pharmacy Services.28 Pa. Code 211.9 (d) Pharmacy Services.28 Pa. Code 211.12 (d)(1) Nursing Services.

Based on review of observation, resident and staff interviews, it was determined that the facility failed to properly secure a medication for one of 12 residents reviewed. (Resident R38).Findings include: A review of Resident R38's clinical record revealed an admission date of January 2, 2026, with a diagnosis of glaucoma (increase eye pressure resulting in the inability of fluid to drain from the inner eye). A review of the physician's order dated January 2, 2026, revealed an order for Dorzolamide HCl ophthalmic solution 2%, instill one drop in both eyes twice daily for glaucoma. On February 9, 2026, at 12:02 p.m., observation revealed the Dorzolamide HCl ophthalmic solution was located in Resident R38's bed. Resident R38 reported that the nurse left the medication at her bedside during the night shift. On February 9, 2026, at 1:59 p.m., an interview was conducted with Resident R38, who reported that at times nursing staff would give (her/him) eye drop medication and Resident R38 would administer the medication (herself/himself). On February 9, 2026, at 2:05 p.m., an observation was conducted with Registered Nurse, Employee E7. Two bottles of Dorzolamide HCl ophthalmic solution were observed-one in the resident's bed and one on the dresser across from the bed. Employee E7 reported that Resident R38 is unable to self-administer medications and that the medication should have been stored in the locked medication cart. On February 9, 2026, at 3:45 p.m. Director of Nursing, Employee E2 also reported that all medications for Resident R38 should be safely stored in the medication cart and Resident R38 is unable to self-administer medications. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.9(b)(c)(d) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement infection control standards related to the use of personal protective equipment and wound care for one of 12 residents reviewed. (Resident R5)Findings Include:Review of memo Enhanced Barrier Precautions in Nursing Homes from the Centers for Medicare & Medicaid Services dated March 20, 2024, revealed enhanced barrier precautions (EBP- involve gown and glove use during high-contact resident care activities ) recommendations include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.Review of facility policy Wound Care revealed staff should use disposable cloth to establish a clean field on resident's overbed table. The licensed staff should place all items to be used during procedure on the clean field and arrange the supplies so they can be easily reached.Further review of facility policy Wound Care revealed staff should wear sterile gloves when physically touching the wound or holding a moist surface over the wound.Review of Resident R5's comprehensive Minimum Data Set (federally mandated resident assessment and care screening) dated January 2, 2026, revealed the resident was admitted to the facility on [DATE], and had at least one or more unhealed pressure ulcers. Review of Resident R5's wound care consult dated February 2, 2026, revealed the resident had an abrasion to his/her left chest with wound care instructions to cleanse with normal saline, apply calcium alginate, and cover with a clean dry dressing with a frequency of daily and as needed.Wound care observation was conducted on February 9, 2026, at 11:00 a.m. with Licensed Nurse, Employee E8, for Resident R5's left chest wound. Licensed Nurse, Employee E8, wore gloves and a mask for personal protective equipment (PPE) during wound care. Observations during wound care for Resident R5 on February 9, 2026, at 11:00 a.m. revealed License Nurse, Employee E8, used sterile gloves to take scissors out of his/her scrubs pocket, use them to cut open the calcium alginate, and then further apply the clean bandage to the open wound.Interview on February 9, 2026, at 12:55 p.m. with Licensed Nurse, Employee E8, confirmed he/she should have applied a new/clean pair of gloves after using the scissors and before applying the clean bandage to the open wound. Further interview with Licensed Nurse, Employee E8, confirmed there was no signage posted on the resident's room door to indicate Resident R5 was on enhanced barrier precautions, and that the employee failed to wear a gown, as required, during wound care.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure the call light was within easy reach for one of 12 residents reviewed (Resident R49). Findings Include:Review of facility policy Answering the Call Light revised October 2010 revealed when the resident is in bed or confined to a chair, the call light should be within easy reach of the resident.Review of Resident R49's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2026, revealed the resident was newly admitted to the facility on [DATE], and had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypoxemia (low blood oxygen levels), need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility.Review of Resident R49's comprehensive care plan dated February 2, 2026, revealed the resident had an activity of daily living self-care deficit related to physical limitations. Interventions dated February 2, 2026, revealed Resident R49 required extensive assistance from staff with toileting, transfers, bed mobility, and dressing.Observations on February 9, 2026, at 10:15 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained of discomfort and requested repositioning. Further observations revealed Resident R49's call light was on the floor and out of reach.Interview/observation on February 9, 2026, at 10:20 a.m. with Licensed Nurse, Employee E6, confirmed Resident R49's call light was not within reach.Observations on February 11, 2026, at approximately 1:24 p.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained about being thirsty and requested water. Further observations revealed Resident R49's call light was out of reach.Interview on February 11, 2026, at approximately 1:25 p.m. with nurse aide, Employee E12, confirmed Resident R49's call light was not within reach.Observations on February 12, 2026, at approximately12:22 p.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Resident R49 complained about being uncomfortable in the wheelchair. Further observations revealed Resident R49's call light was out of reach.Interview on February 12, 2026, at approximately 12:23 p.m. with Licensed Nurse, Employee E6, confirmed Resident R49's call light was not within reach.Observations on February 13, 2026, at 10:58 a.m. revealed Resident R49 was sitting in his/her wheelchair positioned next to the bed. Further observations revealed Resident R49's call light was out of reach.Interview on February 13, 2026, at approximately 11:00 a.m. with licensed nurse, Employee E8, confirmed Resident R48's call light was out of reach.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility assessment and staff interview, the facility failed to ensure include the direct care staff and input from residents, resident representatives and family members when conducting the facility assessment.Findings include: A review of the facility policy titled Facility Assessment, last revised in June 2024, revealed that a facility assessment is conducted annually to determine and update the capacity to meet the needs of, and competently care for, residents during day-to-day operations, including nights, weekends, and emergencies. The policy further describes the team responsible for conducting, reviewing, and updating the facility assessment under bulletin #2. The team includes leadership and management, such as the Administrator, a representative of the governing body, the Medical Director, the Director of Nursing, and other department heads as needed. It also includes direct staff, such as RNs, LPNs/LVNs, nursing assistants, and a representative of the direct staff if applicable. Finally, the policy indicates that residents, resident representatives, and family members may also be part of the team. Review of the facility's facility assessment provided revealed a last revision date of December 8, 2025. There was no indication that the facility involved direct care staff and input from residents. During an interview conducted on February 13, 2026, at 1:00 p.m., the Administrator was asked who participated in the development and revision of the facility assessment. The Administrator stated that the leadership team conducted the facility assessment. When asked whether direct care staff, residents, or resident representatives provided input during the meetings in which the facility assessment was revised, the Administrator did not provide documentation or other evidence to demonstrate that such individuals participated in the process. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on observation, review of clinical records, review of facility documents and interview with staff and residents, it was determined that the facility failed to investigate an allegation of verbal abuse by two of four residents reviewed. (Resident R1 and Resident R2)Findings include: Review facility policy entitled Abuse Prevention Program dated January 1 2022 and reviewed on November 30 2022, revealed that under section Policy Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation this includes but is not limited to freedom from corporal punishment, and voluntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraints not required to treat the resident symptoms. Under section Policy Implementation #6. Identify and assess all possible incidents of abuse. # 7. Investigate and report any allegation of abuse within time frames as required by federal and state requirement. #8. Protect residents during abuse investigation.Review of policy for Abuse investigation and Reporting dated January 1, 2022, and reviewed on November 30 2022, Reveal that under section Policy All reports of resident abuse neglect exploitation misappropriation of resident property mistreatment and or injuries of an own source shall be promptly reported to local state and federal agencies as defined by current regulations and thoroughly investigated by facility management findings of abuse investigation will also be reported. Under Policy Implementation # D the administrator will suspend immediately an employee who has been accused of resident abuse pending the outcome of the investigation #16 The individual conducting the investigation will as a minimum a review the completed documentation forms #c. Interview the person reporting the incident #d. Interview any witnesses to the incident #e. interview the resident as medically appropriate #g. Interview staff members on all shifts who have had contact with a resident during the period of the alleged incident #h. Interview the resident's roommate family members and visitors #j. Review all events leading up to the alleged incident.Review of Resident R1's clinical record Reveal that resident R1 was admitted to the facility on [DATE], with the diagnosis of but not limited to Severe Protein Calorie Malnutrition.Review of Resident R1S MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 15, suggesting that Resident R1 was cognitively intact.Review of the facility grievance log revealed no grievances from Resident R1. Interview with Resident R1 conducted on September 24, 2025, at 9:42AM revealed that Resident R1 complained that the nurse's aide that works during the night shift was so rough with him during care and that she yells at him.Further Interview with Resident R1 revealed that he wrote a complaint about the nurse's aide twice already. Further Resident R1 also revealed that last week, the medication nurse wrote his complaint for him. Further, Resident R1 revealed that nothing has been done to address his complaints. Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R1's grievance, Employee E2 revealed that she will have to ask the social worker. Interview with Licensed Nurse Employee E3 conducted on September 24, 2025, at 12:02 PM revealed that last week either Monday (September 15, 2025) or Tuesday (September 16, 2025), Resident R1 asked her to write his complaints against a night shift nurse's aide who was rough with him during care. Further Employee E3 revealed that she wrote Resident R1's complaints in a grievance form and dropped it into the grievance box located in the unit.Interview with the Social Worker Employee E4 revealed that she regularly checks the grievance box and that did not see any grievance forms in the grievance boxes.Further interview with Employee E4 also revealed that she does not have Resident R1's grievance and that she has not done any investigation related ton Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident R1's complaints that the night shift nurse's aide was rough with him during care.Review of Resident R2's clinical record Reveal that Resident R2 was admitted to the facility on [DATE], was discharged on August 28, 2025, and was readmitted on [DATE], with the diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Morbid Obesity.Review of Resident R2's MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 14, suggesting that Resident R1 was cognitively intact.Interview with Resident R2 conducted on September 24, 2025, at 9:28AM revealed that revealed that the nurse's aides were rough during care and that they yelled at her. Further, Resident R1 revealed that one time, she pushed the call bells 3 times, the staff came in 3 times, and she turned it off telling her I'm busy, I can't do you right now and when she came back, she was rough with me.Further interview with Resident R2 revealed that the nurse's aide that was rough with her during care works on the evening shift. Further Resident R2 revealed that last night during the night shift, an African nurse's aide yelled at her. Further interview with Resident R2 revealed that resident R2 has reported the above complaints to the Director of Nursing and to the Administrator.Review of Resident Concern Report completed by Social Worker Employee E4 dated August 15, 2025, revealed that a voice message from Resident R2's husband was left on August 14, 2025, and was received on August 15, 2025, complaining about being left in bed for hours in feces before someone care in to help her. Further, the Resident Concern Report also revealed that Resident R2's husband complained that his wife was being manhandled. Further, the Resident Concern Report section: Document steps taken to investigate and outcome revealed a statement from Resident R2 stating she push the call bell three times nurse's aide came in three times and turned it off, I'm busy I can't do you right now and when she came back, she was rough with me.Further review of Resident Concern Report revealed no documented evidence that a complete investigation was conducted. There was no statements from staff, there was no findings or conclusion, there was documented action by the facility to address the issues, no staff disciplinary action, there was no staff education.Further review of the report indicated that it was investigated by Employee E2 and Employee E4 on August 15, 2025.Further the facility administrator signed the report on August 18, 2025.Interview with Social Worker Employee E4 conducted on September 24, 2025, at 12:41PM revealed that she identified the nurse's aide involved in Resident R2's complaint and interviewed her. Employee E4 revealed that the nurse's aide told her that Resident R2 had pressed the call bell at least 50 time in 2 hours and that the nurse's aide said that she can't do Resident R2 alone, and that it's hard not be rough because she is such a big lady, there is no gentle want do it Further interview with Employee E4 confirmed that she did not write her interview with the nurse's aide and her statement was not on file.Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R2's complaints, Employee E2 revealed that she did not know because the facility administrator who was no longer working at the facility took care of that investigation.The facility was not able to provide upon request, documented evidence that an investigation was conducted on Resident R1 and Resident R2's allegations of verbal and physical abuse. 28 Pa. Code:201.18(a)(1)(3) Management28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on observation, review of facility policy and interview with staff and residents, it was determined that the facility failed to ensure that grievances are addressed in a timely manner for one of four residents reviewed (Resident R1).Review of the facility's policy entitled Grievances/Complaints, Filing revealed that under section Policy Statement residents and their representatives have the right to file grievances either orally or in writing to the facility staff or to the agency designated to hear grievances (i.e. the State Ombudsman). The Administrator and his staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. Under section Policy Interpretation and Implementation #1 Any resident, family member or appointed resident representative may file a grievance or complaint concerning care treatment, behavior of other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Grievances and or complaints may be submitted orally or in writing or may be filed anonymously. #7. The Administrator has delegated the responsibility of grievance and our complaint investigation to the Grievance Officer. #8. Upon receipt of a grievance and or complain the Grievance Officer will review and investigate the allegations and submit a written report to such findings to the Administrator within five working days of receiving the grievance and or complaint. #9 the grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. #10. The Grievance Officer, Administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. #11. The administrator will review the findings with grievance officer to determine what corrective actions if any need to be taken.Review of Resident R1's clinical record Reveal that resident R1 was admitted to the facility on [DATE], with the diagnosis of but not limited to Severe Protein Calorie Malnutrition.Review of Resident R1S MDS (minimum data set-a federally required resident assessment completed at a specific interval), dated September 10, 2025, revealed that under Section C - Cognitive Patterns,0500. BIMS Summary Score (brief interview for mental status) revealed that Resident R1 was coded 15, suggesting that Resident R1 was cognitively intact.Review of the facility grievance log revealed no grievances from Resident R1. Interview with Resident R1 conducted on September 24, 2025, at 9:42AM revealed that Resident R1 complained that the nurse's aide that works during the night shift was so rough with him during care and that she yells at him.Further Interview with Resident R1 revealed that he wrote a complaint about the nurse's aide twice already. Further Resident R1 also revealed that last week, the medication nurse wrote his complaint for him. Further, Resident R1 revealed that nothing has been done to address his complaints. Interview with DON (director of nursing) Employee E2 conducted on September 24, 2025, at 11:59AM revealed that when asked if she did an investigation on Resident R1's grievance, Employee E2 revealed that she will have to ask the social worker. Interview with Licensed Nurse Employee E3 conducted on September 24, 2025, at 12:02 PM revealed that last week either Monday (September 15, 2025) or Tuesday (September 16, 2025), Resident R1 asked her to write his complaints against a night shift nurse's aide who was rough with him during care. Further Employee E3 revealed that she wrote Resident R1's complaints in a grievance form and dropped it into the grievance box located in the unit.Interview with the Social Worker Employee E4 revealed that she regularly checks the grievance box and that did not see any grievance forms in the grievance boxes.Further interview with Employee E4 also revealed that she does not have Resident R1's grievance and that she has not done any investigation related ton Resident R1's complaints because she never got any grievances.Interview with Director Employee E2 confirmed that there was not aware of any grievances submitted by Resident R1.Further interview with Employee E2 confirmed that the facility did not conduct an investigation related to Resident R1's complaints that the night shift nurse's aide was rough with him during care. Pa. 28 Code: 201.29(i) Resident Rights.

Based on clinical record review, review of facility policies and staff interviews, it was determined that the facility failed to provide nutritional interventions, failed to complete timely nutritional assessments by a qualified nutrition professional, failed to notify physician of weight loss, failed to ensure residents with vegetarian diet received appropriate diet with nutritional value and failed to complete weight assessment to promote acceptable parameters of nutritional status which resulted in Resident R20 experiencing unplanned significant weight loss four times from November 24, 2023 to April 24, 2024, (lost 33.03% (43 pounds) of body weights) and continued to place Resident R20 at risk for further nutritional decline. This failure placed Resident R20 in Immediate Jeopardy situation, for one of three residents reviewed for nutritional risk. (Resident R20) Findings include: Review of facility policy Weight Assessment and Intervention dated September 2008, revealed that Weight Assessment The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment will be retaken the next day for any weight change of 5% or more confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) (usual weight) x 100): 1 month -5% weight loss is significant; greater than 5% is severe a. 3 months =7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. If the weight change is desirable this will be documented and no change in the care plan will be necessary. Analysis Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to dining); f. Increased need for calories and/or protein; g Poor digestion or absorption; h. Fluid and nutrient loss; and/or i. Inadequate availability of food or fluids. 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals: e, Chewing and swallowing abnormalities and the need for diet modifications: f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives. Review of an undated facility policy Vegetarian Diet revealed that, The Vegetarian Diet accommodates the food preference of the individuals avoiding certain animal food in their diet. Upon admission, the nursing staff will submit a Tray Card Slip to the dietary department denoting the physician's order for vegetarian diet. The patient will be placed on a vegetarian diet. Review of facility documentation revealed that the facility had a vegetarian extension of the cycle menu. Review of clinical record revealed that Resident R20 was admitted to the facility with the diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hemiparesis (weakness on one side of the body, including the arms, legs, hands, and face), cognitive communication deficit and dysphagia (difficulty swallowing). Review of Resident R20's Minimum Data Set (MDS- assessment of resident care needs) dated April 7, 2024, revealed that the resident lost more than 5 % the last month and 10% or more in last 6 months and the resident was not on a prescribed weight loss regimen. Review of an admission nutritional assessment dated [DATE], revealed that the resident was on a vegetarian and on a cardiac diet. Resident weighed 132 pounds with a BMI of 20.7, with an estimated calorie need of 2000-2200 kcal 63-83 grams of protein. Review of weight assessment for Resident R20 dated November 1, 2023, revealed that the resident weighed 132 .6 pounds. Review of weight assessment for Resident R20 dated November 28, 2023, revealed that the resident weighed 119.0 pounds which was 10.25 % weight loss in a month (severe weight loss). Review of a re-weight assessment for Resident R20 dated December 1, 2023, revealed that the resident weighed 115.0 pounds which was 13.27 % weight loss in a month (severe weight loss). Review of weight assessment for Resident R20 dated January 2, 2024, revealed that the resident weighed 107.0 pounds which was 6.95 % weight loss in a month and 18.9 % in three months (severe weight loss). There were no monthly weights available for review for the month of February 2024. Review of weight assessment for Resident R20 dated March 29, 2024, revealed that the resident weighed 91 pounds which was 13.33 % weight loss from the last weight of January 5, 2024 of 105 pounds and 31.5 % in six months (severe weight loss). Review of weight assessment for Resident R20 dated April 24, 2024, revealed that the resident weighed 88.8 pounds which was 2.41 % weight loss from the last weight of March 29, 2024. and 33.03 % in six months (severe weight loss). Review of the Registered Dietician's weight change note dated November 30, 2023 in response to a weight on November 28, 2023, revealed that a reweight was requested. No other nutritional interventions were recommended. Review of Registered Dietician's weight change note dated December 4, 2023 in response to a weight on December 1, 2023, revealed that a re-weight was requested. No other nutritional interventions were recommended. Review of Registered Dietician's weight change note dated December 12, 2023 revealed that the dietician requested another re-weight again. Review of Registered Dietician's weight change note dated December 14, 2023, revealed that the dietician requested a re-weight again due to discrepancy in weight and wound management. Recommended to add vitamin C x 14 days. No other nutritional interventions were initiated or recommended related to the resident's weight loss. Review of Resident R20's December 2023 Medication Administration Record revealed that the nutritional recommendation of Vitamin C was not implemented. Resident did not receive the medication as recommended by the Registered Dietician. Review of the weight assessment for Resident R20 revealed that there was no re-weight obtained after December 1, 2023, as requested by the Registered Dietician. Review of Registered Dietician's weight change note dated January 3, 2024, in response to a weight on January 2, 2024, revealed that a re-weight was requested. Review of the Registered Dietician's weight change note dated January 5, 2024, in response to a weight on January 5, 2024 , revealed that the weight loss was confirmed. Resident on cardiac diet, vegetarian. Dietician recommended to liberalize the diet and discontinue cardiac diet. Recommended to start house shake (protein supplement) once daily, magic cup (protein supplement) once daily and weekly weights for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for the month of January 2024 revealed that the supplements were not initiated and given as recommended. No weekly weights were completed. Physician was not notified. There were no monthly weighs available for the month of February 2024. Review of dietician progress note dated January 29, 2024, revealed that the dietician recommended to add Vitamin C 500 mg twice daily, start multivitamin with minerals and zinc. Review of clinical record revealed that the above recommendations were not initiated or provided to the resident. There was no nutritional assessment from January 29, 2024 to April 1, 2024. Review of clinical record for January 2024 and February 2024 revealed no evidence that the above recommendations were implemented. Review of physician order dated March 2024, revealed that it was not until March 2024 that an order was obtained for the nutritional supplement Mighty shake (products with extra calories and protein in a tasty drink that is rich and creamy like a milkshake). Review of the Registered Dietician's weight change note dated April 1, 2024, revealed that the dietician requested a re-weight again. Review of the Registered Dietician's weight change note dated April 3, 204, revealed that the dietician documented diet not liberalized as recommended. Intake >50 % for most meals, given that he follows vegetarian lifestyle, liberalizing diet would offer more option. Current BMI (body mass index) 14.3- under weight. To also recommend weekly weights to follow. Review of clinical record for Resident R20 for month of April 2024 revealed that there were no weekly weights completed as ordered. Review of the Registered Dietician's weight change note dated April 28, 2024, in response to a weight on April 24, 2024, revealed that resident lost significant weight and weighed 88.8 pounds. Weight loss continued, recommended to add the nutritional supplement Boost breeze, requested to add percentage consumed for the supplements for monitoring. It was also revealed that it was recommended to notify the physician of the weight loss. Review of clinical record for May 2024 revealed that the boost breeze was not started, mighty shake percentage consumed was not documented, weekly weights were not initiated, and the physician was not notified as recommendations by the dietician as of May 3, 2024. Observation of Resident R20's meal intake dated May 7, 2024, at 12:30 p.m. revealed that the resident was observed taking couple bites of a vegetable burger, a nursing assistant asked the resident how the food was. He replied horrible. The nursing assistant walked away from the resident without offering alternatives. Interview with Food Service Director, Employee E13, on May 7, 2024, at 3:11 p.m. stated he was aware that the resident was on a vegetarian diet. He stated kitchen made vegetarian dishes like salads, vegetable burgers as available in the kitchen. He stated she was not aware of a vegetarian menu extension which has been approved by a dietician based on appropriate nutritional needs. Employee E13 stated he was not sure how much calorie intake the resident had or had no documentation of what kind of food the resident received for the past 4 months. Employee E13 confirmed that the facility did not follow the approved vegetarian menu. Interview with Registered Dietician, Employee E6, on May 7, 2024, at 2:46 p.m. stated that Resident R20 had lost significant weight over the last 6 months. She stated she made recommendations in response to weight loss multiple times, but the interventions were not implemented as recommended. She stated she only worked 2 days a week and it was not possible to track weight loss with limited time available. Registered Dietician, Employee E6 also confirmed that the weekly weights were not started, and no interventions were in place after residents last weight of 88.8 which was a significant weight loss. Registered Dietician, Employee E6 stated she did not notify the physician; it was supposed to be the nursing department who notified the physician. Interview with Regional Food Service Staff, Employee E14, on May 8, 2024, at 12:00 p.m. stated facility had approved vegetarian menu extension. Employee E13 did not know how to find it as a result it was not followed. Interview with physician for Resident R20, on May 7, 2024, at 2:00 p.m. stated she was not aware of Resident R20's weight loss. She stated she always approved dietary recommendation unless it created too many medications for residents. Physician stated Resident R20 is severely contracted, so it was possible to identify weight loss from observation and weight was required. Physician confirmed that the resident did not have any diagnosis or disease condition which created an unexplained weight loss. A request for meal intake consumption record for Resident R20 for last 4 months was requested to the facility administrator on May 7, 2024, May 8, 2024, and May 10, 2024. However, facility did not submit meal intake documentation. Review of available meal intake consumption record form April 9, 2024, to May 9, 2024, it was revealed that facility did not document any meal consumption for April 12, May 2, May 4, May 5, 2024. Facility only documented on meal intake on April 9, 10, 16, 20, 24, 26, 27, 2024; May 1, 3, 6, and 7, 2024 missed two meal intake documentation for these dates. Facility documented only two meal intake documentation on April 13, 15, 17, 18, 21, 28, 2024 and missed one meal documentation for these dates. Review of clinical record for Resident R20 on May 7, 2024 revealed that there was no weekly, weights implemented, no dietary recommendation from April 28, 2024 implemented, no physician notification and evaluation completed for Resident R20 in response to weight loss, facility did not follow approved vegetarian diet with appropriate nutritional value and did not monitor meals intake appropriately. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, on May 9, 2024, at 1:30 p.m. for the facility's failure to implement dietary recommendation as ordered by the Registered Dietician and failed to follow the facility approved vegetarian diet for Resident R20, who was assessed as nutritionally at risk and preferred a vegetarian diet. The facility failed to monitor meal intake, to notify the physician and to complete a physician assessment in response to a significant weight loss. This failure resulted in the resident experiencing a significant weight loss on December 1, 2023, had a further significant weight loss on, January 5, 2024, March 29, 2024, and on April 24, 2024. This continued failure placed Resident R20 in harm at risk for further weight loss and further harm without appropriate interventions. An immediate jeopardy template (a document which included information necessary to establish each of the key components of the immediate jeopardy) was provided to the Nursing Home Administrator on May 9, 2024, at 1:30 p.m. The facility submitted a written plan of action on May 9, 2024, at 5:00 p.m. and implemented the plan of action which included: -On 5/8/2024 the facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that the residents in the facility with concerns regarding weight loss were addressed by the physician/dietician and that recommendations were implemented if applicable; resident food preferences were being honored, to ensure that meal consumption amounts are being properly monitored and documented and to ensure that current policies were reviewed with changes made as indicated. -Resident 20 was reweighed, and the dietician and physician were notified to implement interventions as needed on 5/8/2024. -The resident was reassessed by the physician on 5/9/2024. -The resident was re-interviewed by the dietary manager 5/9/2024 to update preferences related to preferred vegetarian diet. -Current facility residents were re-weighed on 5/8/2024 and 5/9/2024. The physician and dietician were notified of any significant changes with interventions implemented if applicable. -Currently facility residents were interviewed by the Certified Dietary Manager on 5/9/2024 to ensure their diet preferences were up-to-date and to ensure their preferences were being honored. An additional audit of the meal tracker system was completed by the Certified Dietary Manager to ensure that orders accurately reflected residents' current preference. -Dietary recommendations for the last 30 days were reviewed on 5/9/2024 to ensure that any recommendations made were implemented. -Facility Licensed Nurses received education on starting on 5/8/2024 and will be completed on 5/9/2024 from the Director of Nursing regarding the procedures for obtaining resident weights and notifying the physician and dietician of any significant changes, along with implementing dietary recommendations in a timely manner. -Facility clinical staff received education starting on 5/9/2024 and will be completed on 5/9/2024 from Director of Nursing on ensuring that resident meal intake is appropriately monitored and documented. -Facility Dietary Staff will receive education from the CDM starting on 5/9/2024 and will be completed on 5/9/2024 on ensuring that residents are receiving the appropriate diet based on their preferences. -An Ad Hoc QAPI Meeting was held on 5/9/2024 to discuss the events surrounding the resident's weight loss, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding obtaining weights, communication with the IDT team when significant changes occur, implementing physician/dietician recommendations in a timely manner and ensuring that resident meal preferences are honored. -Any staff member that did not receive education related to the above mentioned was notified by the staffing coordinator verbally via phone indicating they may not return to work until the education is received. -Newly hired staff will receive education in orientation -Education for respective facility staff as stated above, weekly weight meetings with the members of the interdisciplinary team to ensure that weights are being obtained and any significant changes are addressed immediately with the appropriate team members to include the physician, verbally while in the facility and via phone call when not present; the dietician will be present in the weekly weight meetings and will provide a paper copy of recommendations made; an additional copy of recommendations will be provided to the facility in the form of an electronic copy via email to the NHA, DON, and CDM; care plans are active and reflect appropriate interventions related to the residents' current nutrition and weight status. -Audits will be conducted as follows: bi-monthly resident interviews by the CDM to ensure that resident food and diet preferences remain up to date; random audits of 5 residents weekly to ensure that food intake is being appropriately monitored and documented. -Actions to be completed on 5/9/2024 -The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Improvement Committee weekly. Quality Review schedule modified based on findings. On May 10, 2024, the action plan was reviewed, clinical records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on May 10, 2024, at 3.58 p.m. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility documentation, hospital records, observations and staff interview, the facility failed to provide adequate monitoring and assessment to ensure the safety of one resident with suicide ideation resulting in actual harm of a bone fracture in the neck to one resident, and it was determined that the facility failed to provide supervision and monitoring related to resident falls for one of 24 records reviewed (Residents R102 and R10). Findings include: Review of Resident 102's clinical record revealed physician orders [REDACTED]. Additionally, the physician ordered that the resident be medicated with [MEDICATION NAME] (medication to treat depression) 150 milligrams by mouth daily and [MEDICATION NAME] (to treat hallucination) 2.5 milligrams by mouth at bedtime. Psychiatric documentation dated (MONTH) 5, (YEAR), revealed that the resident had previously attempted suicide two times. On one occasion the resident overdosed on medication and was found unconscious and on another occasion the resident had jumped in front of a train. It stated further that the resident was unkempt, thought process was confused, had poor insight, had impaired intellectual functioning, was suspicious, paranoid, mood was worried/anxious. A resident plan of care was developed to address the use of [MEDICAL CONDITION] medications for anxiety and depression, revised (MONTH) (YEAR), which included interventions such as medications as ordered by physician, monitor and record behavior symptoms, verbalize feelings, monitor and report side effects of psychoactive medications, provide emotional support and psychiatric evaluation as needed. Review of nursing progress notes dated (MONTH) 7, (YEAR), at 7:47 p.m. revealed that the resident's spouse had notified the facility at 7:25 p.m. the resident had telephoned the spouse and stated that he was feeling suicidal, upon assessment the resident stated to the nurse that he was feeling suicidal and wanted to go the emergency room , the physician was notified and the resident was transported to the emergency room and was admitted to the hospital. A review of hospital transfer documentation dated (MONTH) 13, (YEAR), revealed a [DIAGNOSES REDACTED]. The resident had been seen by psychiatry staff and a geriatric psychiatric inpatient hospitalization had been recommended but the resident's spouse refused. Nursing documentation stated that resident R102 returned to the facility at 2:00 p.m. on (MONTH) 13, (YEAR), by stretcher from the hospital with admitting [DIAGNOSES REDACTED]. Employee E11, the facility administrator at the time of the event, stated in an interview on (MONTH) 22, (YEAR), at approximately 12:00 p.m. that after Resident R102's hospitalization on (MONTH) 7, (YEAR), the hospital psychiatric staff had recommended that the resident go to an inpatient psychiatric hospital, that Resident R102's spouse had refused to send the resident and the facility felt the resident had returned to baseline. There was no evidence available for review, at the time of the survey, that Resident R102's plan of care had been revised after he returned with interventions developed to address the resident's suicide ideation. In addition, there was no evidence available to indicate that the resident was being assessed or monitored more closely for self-harming behavior. A Late Entry Health status note dated (MONTH) 16, (YEAR), stated that the nurse had administered [MEDICATION NAME] (antianxiety medication), gave the resident a urinal and left the room and went to the nurses station. The nurse aide said that she heard three loud thumps, ran in the room to see what had happened and came running out saying the resident was bleeding and there was blood coming from the resident's head. An investigation dated (MONTH) 16, (YEAR), at 1:20 p.m. stated that Resident R102 was found crawling into bed with bed dripping down his forehead from a laceration above his eye and discoloration beside his nose and below his eye. A written statement by the nurse aide revealed that a Boom, boom, boom was heard and the staff member ran into the resident's room and found the resident was on the floor with his head bleeding, crying that he threw himself to the floor because he wanted to go to the hospital. A report submitted by the facility (required submission of incidents and accident reports) dated (MONTH) 17, (YEAR), stated that staff heard three loud repeating thumps and upon entering Resident R102's room the resident was on his hands and knees with blood dripping from his head. Review of emergency room documentation revealed that the resident had arrived on (MONTH) 16, (YEAR), at 2:21 p.m. and that just prior to arrival staff heard a loud noise, entered the resident room and resident was found on the floor crawling to get back into bed. The EMT (Emergency Medical Technician) stated that the resident had been on suicide watch and threw self on floor. Further emergency room documentation at 5:14 p.m. noted that the facility had called and stated that Resident R102 threw himself out of the bed and they were concerned about suicide ideation. The resident was transferred to the geriatric psychiatric unit once he was medically cleared. emergency room physician documentation for (MONTH) 16, (YEAR), at 2:56 p.m. noted that the resident had a laceration to the forehead, approximately 1/2 inch long that required 4 sutures. A CAT (computerized axial tomography) Scan (x-ray images taken at different angles) was performed on (MONTH) 16, (YEAR), at 4:27 p.m. and indicated Resident R102 had an avulsion (a fragment of bone that is torn off due to trauma) fracture at C3 (cervical bones near the base of the neck). There was no evidence available for review, at the time of the survey, that appropriate interventions to address Resident R102's suicide ideation had been developed. Additionally, there was no evidence available for review, at the time of the survey, that Resident R102's continuing thoughts of suicide or self-harm were being monitored or managed by the staff after the resident returned to the facility on (MONTH) 13, (YEAR), resulting in actual harm to the resident. Resident R10 was admitted to the facility on (MONTH) 30, (YEAR), following surgery to repair a left [MEDICAL CONDITION] on (MONTH) 27, (YEAR). [DIAGNOSES REDACTED]. Review of the facility incident reports revealed that the resident had eight falls between (MONTH) 15, (YEAR), and (MONTH) 19, (YEAR). Two of the falls occurred at the nurse's station and two of the falls occurred on the same day. On (MONTH) 15, (YEAR), at 10:30 p.m. the resident fell out of bed. On (MONTH) 22, (YEAR), at 4:15 p.m. the resident was observed on the floor of her room. On (MONTH) 30, (YEAR), at 3:20 p.m. the resident was observed on the floor of her room. On (MONTH) 9, (YEAR), at 8:30 a.m. the resident was observed on the floor of her room. On (MONTH) 13, (YEAR), at 4:06 a.m. the resident was observed on the floor of her room. On (MONTH) 14, (YEAR), at 2:47 p.m. the resident was at the nurse's station when she slid out of the wheelchair. The resident stated, at that time, that she wanted to go home or to the movies. Later that day at 9:15 p.m., the resident was observed sitting on the floor. On (MONTH) 17, (YEAR), at 10:30 p.m. the resident was observed on the floor of her room. On (MONTH) 19, (YEAR), at 1:29 p.m. while sitting in a wheelchair across from the nurse's station, the resident was observed falling out of the wheelchair. The wheelchair landed on the resident. There was a staff person present at the time of the fall. The next day, the resident was observed in a Rock-N-Go chair (a wheelchair with a rocking motion that helps calm the resident). On (MONTH) 21, (YEAR), the resident was back in a wheelchair. The resident 's care plan dated (MONTH) 2, (YEAR), was reviewed with the Unit Manager, E3, on (MONTH) 22, (YEAR), at 8:10 a.m. The interventions for fall prevention included the following: the resident was to be monitored in common areas, activities to promote exercise and strength building was to be provided, incontinence check and care was to be provided multiple times on 11-7 shift and the resident was to be taken to activities of her choice. The care plan did not provide a schedule for rendering incontinence care or a means for determining that the task was done. Review of the Activity Attendance Record on (MONTH) 21, (YEAR), at 2:30 p.m. revealed the One-to-One log book and the electronic record of completed tasks for Resident R10. The Activity Attendance Record revealed the following: June 9th, the resident did not attend any programs. June 13th, the resident attended 2 programs. June 14th, the resident attended 1 program. June 19th, the resident did not attend any programs. An interview with the Director of Activities on (MONTH) 21, (YEAR), at 2:00 p.m. revealed that activity programs last approximately 30 minutes. There are no specific programs for residents with dementia. The facility failed to provide supervision and monitoring related to resident falls. Additionally, the facility failed to provide ongoing monitoring, assessment and development of interventions to address depression and suicidal thoughts of a resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/15/18, 07/20/17 28 Pa. Code 201.18(b)(1) Management Previously cited 02/15/18, 07/20/17 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/15/18, 06/03/16 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 02/15/18, 07/20/17, 06/03/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 02/15/18, 07/20/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 07/20/17, 06/03/16