Every finding on record at Buffalo Valley Lutheran Villag

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician appropriately addressed pharmacy recommendations for three of five residents reviewed for unnecessary medications (Residents 17, 40, and 69). Findings include: The facility policy entitled Drug Regimen Review, last reviewed without changes April 10, 2026, revealed that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The licensed pharmacist will report in writing any irregularities to the attending physician, the facility's medical director, and the Director of Nursing to be acted upon. Irregularities will be documented on a separate, written report and sent to the physician, medical director, and Director of Nursing, listing the resident's name, relevant drug and irregularity the pharmacist has identified. The physician will document in the resident record that the identified irregularity has been reviewed, and any action taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record. All medication regimen review documents will be maintained in the resident medical record Clinical record review for Resident 40 revealed a consultant pharmacist review dated July 17, 2026, noting Resident 40 has a diagnosis of dementia and receives Quetiapine (an antipsychotic medication) 50 milligrams (mg) in the morning and 100 mg at bedtime. Resident 40's physician requested the facility attempt a gradual dose reduction of Resident 40's Quetiapine or document a rationale for declining. Resident 40's physician accepted the consultant pharmacist recommendation (undated) and outlined a four-week plan to decrease Resident 40's Quetiapine. An unidentified person wrote family is refusing due to maintaining quality of life. This statement wasn't signed or dated. Further review of Resident 40's clinical record revealed the facility did not attempt a gradual dose reduction of Resident 40's Quetiapine as agreed to by Resident 40's physician. Clinical record review for Resident 17 revealed a consultant pharmacist recommendation dated May 2, 2026, noting Resident 17 is [AGE] years old and may benefit from de-prescribing. The consultant pharmacist recommended considering discontinuing Resident 17's Rosuvastatin (medication used to lower cholesterol and reduce the risk of heart disease, heart attack, and stroke) and Calcitonin nasal spray. There was no response from Resident 17's physician. A staff identified by the Nursing Home Administrator as a nurse wrote (undated) per doctor XXX no changes at this time. The above findings for Residents 40 and 17 were reviewed with the Nursing Home Administrator on August 26, 2026, at 2:20 PM. Clinical record review for Resident 69 revealed consultant pharmacist report dated November 13, 2025, which indicated that a medication regimen review was performed and recommended a GDR (gradual dose reduction) for Resident 69's Quetiapine (a type of antipsychotic medication) 12.5 milligram dose. The physician response indicated they were declining the recommendation because the family does not want it changed. The physician did not provide any clinical basis for this decision. Clinical record review for Resident 69 revealed consultant pharmacist report dated February 26, 2026, which indicated that a medication regimen review was performed and recommended a GDR for Resident 69's Quetiapine 12.5 milligram dose. The physician response indicated they were declining the recommendation because the family wishes it to stay the same. The physician did not provide any clinical basis for this decision. The surveyor requested any further documentation available related to Resident 69's GDR on August 25, 2026, at 2:30 PM during a meeting with the Nursing Home Administrator and Employee 5, registered nurse. No further information indicating the physician decision to continue Resident 69's antipsychotic medication was provided. The above findings regarding Resident 69's consultant pharmacist reports were reviewed with the Nursing Home Administrator on August 27, 2026, at 10:30 AM. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of four residents reviewed (Residents 40 and 69). Findings include: Clinical record review for Resident 40 revealed the facility admitted her on February 5, 2026, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 40's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 11, 2026, indicated that the facility assessed Resident 40 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 40's care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 69 revealed a current medical diagnosis list including dementia. Further review revealed that their annual MDS, completed on May 8, 2026, indicated the resident was assessed as having dementia and that a care plan for dementia and cognitive loss would be developed. Review of Resident 69's care plan under impaired cognitive function/dementia or impaired thought processes related to dementia revealed general basic interventions such as anticipating resident needs, asking yes/no questions, and keep routine consistent. There was no indication that the facility had implemented an individualized person-centered care plan to address the residents' specific dementia and cognitive loss needs. Interview with Employee 4 (social services) on August 27, 2026, at 10:18 AM confirmed the above findings for Residents 40 and 69. The findings were reviewed with the Nursing Home Administrator on August 27, 2026, at 11:50 AM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to complete required background check screening for one of five newly hired employees reviewed (Employee 2) and failed to train a new employee on abuse for one of five newly hired employees reviewed (Employee 1). Findings include: The facility policy entitled Abuse Prevention Program- Pennsylvania Only, last reviewed without changes April 10, 2026, revealed all employees and volunteers shall receive training on abuse, neglect, and misappropriation of resident property upon hire, and annually. A criminal record check is conducted on all candidates for employment pursuant to PA (Pennsylvania). In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and a Federal Bureau of Investigation (FBI) Background Check. Review of Employee 2's (laundry) personnel record revealed the facility hired her on May 11, 2026. Employee 2 did not attest to living in Pennsylvania for two years prior to her hire and the facility was unable to provide evidence that a FBI background check was completed. Interview with the Nursing Home Administrator on August 27, 2026, at 11:38 AM confirmed the above findings for Employee 2. Review of Employee 1's (dining services associate) personnel record revealed the facility hired her on June 24, 2026. Further review of Employee 1's personnel file revealed the facility did not train Employee 1 on abuse at the time of her hire. Employee 1 received training on abuse and neglect on July 24, 2026. Interview with Employee 3 (human resources) on August 27, 2026, at 9:12 AM confirmed the above findings for Employee 1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(1)(10) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and residents' representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for two of two residents reviewed for hospitalizations (Resident 72 and Resident 74). Findings include: Clinical record review for Resident 72 revealed nursing documentation dated August 16, 2026, 1:21 PM, Resident 72 was found on the floor, and order was given to send her to ED (emergency department). There was no documented evidence that the resident received a written notification of transfer and bed hold information, and that it was only provided to the responsible party. Clinical record review for Resident 74 revealed nursing documentation dated July 2, 2026, at 2:39 PM an order was received to send the resident to the hospital to be evaluated for respiratory distress. There was no evidence Resident 74 received a written notice of transfer and bed hold information at the time of transfer and that the information was only provided to the responsible party. Interview with the Nursing Home Administrator on August 27, 2026, at 11:15 AM, confirmed that the facility did not provide Resident 72 and Resident 74 with copies of written transfer or bed-hold notices as noted above. 28 Pa. Code 201.14(a) Responsibility of license

Based on clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan for an implanted medical device and a PICC (peripherally inserted central catheter) for one of 17 residents reviewed (Resident 4). Findings include: Clinical record review for Resident 4 revealed a diagnosis list that included the presence of an automatic implantable cardiac defibrillator (an electronic device to help regulate the beating of the heart and can deliver an electrical shock to restore a normal heartbeat), atrial fibrillation (an irregular heart rhythm), and sudden cardiac arrest. Nursing documentation for Resident 4 dated July 24, 2026, at 1:39 PM revealed the resident was admitted to the facility and has a pacemaker. Hospital documentation for Resident 4 dated July 13, 2026, at 8:44 PM noted the resident has an ICD (implantable cardiac defibrillator). An interview with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident reported an implanted cardiac defibrillator. Review of Resident 4's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's device, any pertinent assessments and/or clinical care concerns related to the device, or any associated precautions. The care plan related to Resident 4's implanted device was requested during a meeting with the Nursing Home Administrator and Interim Director of Nursing on August 25, 2026, at 2:15 PM. The facility provided an updated care plan (after surveyor questioning) to include that Resident 4 has a pacemaker and to test per orders. Observation during the interview with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident also has a peripherally inserted central catheter (PICC; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the right arm. The resident reported the PICC was for antibiotics due to an infection. Further review of Resident 4's clinical record revealed an order dated July 28, 2026, for a single lumen power PICC in the right upper arm. There was also an order dated July 24, 2026, at 9:00 PM for an antibiotic to be administered two times a day intravenously (IV, administered into a vein). Review of Resident 4's care plan revealed that the resident is on antibiotic therapy. An intervention dated July 24, 2026, instructed staff to maintain the PICC line as ordered. There was no comprehensive, person-centered care plan that addressed the resident's PICC such as any pertinent assessments and/or clinical care concerns related to the device (assessment of the device or monitoring for any complications such as edema, catheter migration, or infection), or any associated precautions/restrictions. The care plan related to Resident 4's PICC was requested during a meeting with the Nursing Home Administrator and Interim Director of Nursing on August 26, 2026, at 2:15 PM. There was no additional information in the care plan provided by the facility. The facility failed to implement a comprehensive, person-centered, care plan for Resident 4 related to the implanted device and PICC. The Nursing Home Administrator was informed of the concerns with Resident 4's care plan on August 27, 2026, at 11:38 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding medication parameters for one of 17 residents reviewed (Resident 15) and failed to ensure the availability of necessary emergency supplies as per the physician order for one out of one resident reviewed with a PICC (Resident 4). Findings include: An interview and subsequent observation with Resident 4 on August 25, 2026, at 11:53 AM revealed that the resident currently has a peripherally inserted central catheter (PICC; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the right arm. The resident reported the PICC was for antibiotics due to an infection. Review of Resident 4's clinical record revealed an order dated July 28, 2026, for a single lumen power PICC in the right upper arm. There was also an order dated July 24, 2026, at 9:00 PM for an antibiotic to be administered two times a day intravenously (IV, administered into a vein). Further review of Resident 4's clinical record revealed a physician order dated July 24, 2026, for a pressure dressing and hemostats at bedside. During the medication pass observation on August 26, 2026, at 12:58 PM with Employee 6, licensed practical nurse, the staff member reported the pressure dressing and hemostats should be located on the IV pole in the resident's room. Employee 6 was unable to locate the pressure dressing or hemostats at the bedside. Employee 6 proceeded to check the medication cart in the hallway outside of the resident's room and also the locked medication/staff room on the unit across from the dining room area and was not able to locate the pressure dressing and hemostats at that time. A later interview with Employee 6 on August 26, 2026, at 1:36 PM revealed that the staff member had found the bag with the pressure dressing and hemostats in the other cart. The above information was reviewed during the meeting on August 26, 2026, at 2:15 PM with the Nursing Home Administrator and interim Director of Nursing. The facility failed to ensure the availability of necessary emergency supplies at bedside as per the physician order. Clinical record review for Resident 15 revealed a diagnosis list that included essential (primary) hypertension (high blood pressure) Clinical record review for Resident 15 revealed a current physician order dated December 15, 2025, at 8:00 AM for Losartan Potassium (a medication that lowers the blood pressure) give 25 milligrams (mg) by mouth one time a day for essential (primary) hypertension. The order noted to hold the medication for a systolic blood pressure (SBP; the top number of a blood pressure reading where the heart contracts) less than 120. Further review of the physician orders for Resident 15 revealed a current physician order dated December 15, 2025, a t 8:00 AM for Metoprolol Succinate ER (extended release) 24-hour (a medication that is used to treat high blood pressure and/or heart rate); give 50 mg by mouth one time a day related to essential (primary) hypertension. The order noted to hold the medication for a systolic blood pressure less than 100 or a heartrate less than 60. A review of the Medication Administration Record (MAR) for Resident 15 for July and August 2026 revealed that the Losartan was marked as administered outside of the physician specified parameters for the following dates: July 6, 2026; blood pressure was documented as 119/85.August 3, 2026; blood pressure was documented as 108/57August 6, 2026; blood pressure was documented as 114/74 A review of the MAR for Resident 15 for July and August 2026 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following dates: July 27, 2026; pulse documented as 58. There was no documentation for Resident 15 to indicate a rationale for why the medication was administered outside of the specific stated parameters. The Nursing Home Administrator was advised of the findings on August 27, 2026, at 9:08 AM. An interview with Employee 5, registered nurse, on August 27, 2026, at 11:55 AM confirmed that the medications were given outside of the physician ordered parameters. 483.25 Quality of CarePreviously Cited 9/26/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with medication, indwelling catheter care, wound care, and tube feeding for two of three employees reviewed (Employees 7 and 8).Findings include: A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) revealed that the facility had a total of six residents with indwelling urinary catheters and at least one resident with tube feedings. A review of sampled residents of the current resident population revealed that the facility had multiple residents that received medications and had various wounds. A review of the Facility Assessment noted a section for staff competencies. The competencies for registered nurse and licensed practical nurse staff included (in part): medication administration, catheterization/foley catheter care, wound care / VAC (vacuum-assisted closure) dressing, and tube feeding. A request by the surveyor for staff competencies that included medication administration, catheterization/catheter care, wound care, and tube feeding was made for Employee 7 (registered nurse). Competencies that included wound care, medication administration, and tube feeding were also requested for Employee 8 (licensed practical nurse). These competencies were requested during a meeting with the facility on August 26, 2026, at 2:15 PM and again on August 27, 2026, at 11:13 AM. Facility documentation titled LVN/RN Skills Competency Checklist dated June 20, 2026, for Employee 7, noted a checklist with various nursing skills. The document further noted to, Please rate your skill level by checking the appropriate box using the key below. However, there was no noted evaluator assessment or competencies associated with the skills listed in the document and the document was noted to be self-rated. The facility provided a skills fair sign-in dated January 20, 2026, however Employee 7's and Employee 8's signatures were not noted on the sign-in sheet as having attended. The facility provided no competency evaluations or associated documented competency demonstrations that were noted for Employee 7 and Employee 8. An interview with the Nursing Home Administrator on August 27, 2026, at 1:00 PM revealed the facility was unable to produce any further documentation that the above employees had completed competency evaluations in the areas requested. 483.35 Nursing ServicesPreviously cited deficiency 9/26/25 28 Pa Code 201.20(a)(6)(d) Staff development

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to practice appropriate handwashing technique to distribute food in a manner to prevent potential food borne illness on two of four open nursing units (Chestnut and Country Lane, Employees 1, 2, 3, and 4).Findings include: The facility policy entitled, Personal Hygiene and Health Reporting, last reviewed April 10, 2026, revealed that all food and nutrition services employees will be trained in appropriate personal hygiene and health reporting. Personal hygiene criteria to follow include that hands should be washed in the designated handwashing sinks and hair restraints must be worn around exposed foods, in the kitchen, food service areas, and dining areas. The facility policy entitled, Handwashing/Hand Hygiene, last reviewed on April 10, 2026, revealed that all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Steps in the Procedure for Washing Hands list to lather hands with soap under a moderate stream of running water, rinse hands under running water, dry hands thoroughly with paper towels, and then turn off faucets with a clean, dry, paper towel. Observation of the lunch meal food service on the Chestnut nursing unit on July 2, 2026, at 11:58 AM revealed Employee 1 (dietary) used gloved hands to obtain temperature assessments of food on the steam table. Continued observation of Employee 1 on July 2, 2026, at 12:00 PM revealed her to remove her gloves and wash her hands in the unit kitchenette area. Employee 1 washed her hands and used her clean, wet, hand to turn off the faucet before obtaining a disposable paper towel to dry her hands. Employee 1, then, donned new gloves before serving food items from the steam table to resident plates. Observation of the Country Lane lunch meal food service on July 2, 2026, at 12:08 PM revealed Employee 2 (dietary) washed her hands in the kitchenette area that had foods held in the steam table. Employee 2 had no paper towels accessible to her in the sink area to dry her hands; therefore, used her clean, wet, hands to operate a keypad lock to exit the kitchenette. Employee 2 returned to the kitchenette area on July 2, 2026, at 12:09 PM drying her hands with a disposable paper towel. Interview with Employee 2 on July 2, 2026, at 12:09 PM confirmed that she had no paper towels accessible to her in the kitchenette area. Employee 2 confirmed that there was no paper towel dispenser in the sink area in the Country Lane kitchenette. Observation of the Country Lane nursing unit on July 2, 2026, at 12:17 PM revealed Employee 3 (housekeeping) enter the kitchenette area to place an approximately 12-inch stack of disposable paper towels in an open basket on the counter next to the sink. Employee 3 was not wearing a hair net. A sign on the wall before entering the kitchenette area instructed people to not enter the area without a hair net. Observation of the Country Lane nursing unit kitchenette area on July 2, 2026, at 12:24 PM revealed Employee 4 (dietary manager) washed her hands in the kitchenette sink. Employee 4 used her clean, wet, hand to turn off the faucet before obtaining a paper towel from the open stack to dry her hands. Interview with Employee 4 on July 2, 2026, on the date and time of the observation confirmed that there was no covering on the disposable paper towels to prevent potential contamination while stored near the sink. Employee 4 indicated that the dietary department staff recently completed in-service education regarding proper handwashing techniques. The surveyor reviewed the above concerns related to staff handwashing in the nursing unit kitchenette areas during distribution of resident food during an interview with the Nursing Home Administrator on July 2, 2026, at 12:44 PM. 483.60(i)(1)(2) Food Procurement, store/prepare/serve-SanitaryPreviously cited deficiency 9/26/25 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen.Findings included: Observation of the facility's main kitchen with Employee 6, dietary manager, on September 23, 2025, at 9:03 AM revealed the following: The splash guard on the wall adjacent to the dishwasher had a black, greasy build-up on it and the surrounding hoses. The dishwasher room had a rack holding various items. The bottom shelf of the rack held various cooking pans that were identified as clean by Employee 6. The cooking pans and the splash guard under them contained a significant number of debris, crumbs, and dirt and were not protected from the ambient environment. The floor of the walk-in cooler had debris, which included food debris and dirt, especially under the food storage racks. There were two red-colored puddles of fluid on the floor of the cooler. The bottom shelf of a rack held a box of chicken breasts with rib meat and had a puddle of unidentified fluid on it next to the food item. The walk-in freezer had a package of ravioli with a use by date of September 2, 2025, and waffles with a use by date of May 11, 2025. Two black-colored, wheeled carts had an extensive build-up of grease and dirt. A stainless-steel table that had a coffee machine on top of it had debris build-up in the shelving area underneath. There were brown colored dried stains on the wall next to the coffee machine. A storage area had a shelving rack that held various cooking pans on the bottom shelf. There was an extensive build-up of cobwebs between the cooking pans and the wall. There was no splash guard protecting the items on the bottom rack from mop splash. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 24, 2025, at 2:00 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to appropriately implement a safety intervention to prevent potential resident injury for one of eight residents reviewed for accidents (Resident 6); and failed to ensure an environment free from potential accident hazards for residents with elopement behaviors for one of one resident reviewed for elopement concerns (Resident 4). Findings include: The State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, requires facilities to provide an environment that is free from accident hazards over which the facility has control, which includes implementing interventions to reduce hazards and risks. Observation of Resident 6's bedroom on September 23, 2025, at 12:35 PM, September 24, 2025, at 2:55 PM, and September 25, 2025, at 11:40 AM revealed the resident was lying in bed and the bed was not in a low position. Interview with Employee 13, licensed practical nurse, on September 25, 2025, at 11:40 AM revealed that the resident bed had been elevated for resident care and was not returned to a low position. Clinical record review for Resident 6 revealed a physician's order active since May 5, 2025, for a low bed. The care plan initiated on June 21, 2025, lists a low bed as an intervention related to fall prevention. The facility failed to implement the planned accident interventions for Resident 6 indicated by the physician's order and care plan. The above information was reviewed with the Nursing Home Administer and the Director of Nursing on September 25, 2025, at 2:45 PM. The State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, defines elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. Clinical record review for Resident 4 revealed that the facility admitted her on July 17, 2025, to the first-floor [NAME] nursing unit. A physician's order dated July 17, 2025, instructed staff to ensure that a wander guard (wander guard is a wireless system that protects memory care residents from elopement with bracelets and door controllers) device was placed and blinking every shift. A baseline plan of care dated July 17, 2025, indicated that the facility identified Resident 4 had a risk for wandering and elopement. An elopement evaluation dated July 17, 2025, at 2:10 PM revealed that Resident 4 had a history of elopement while at home, and her wandering behavior had both a pattern/was goal-directed and that she wandered aimlessly (was non-goal-directed). Observation of the [NAME] nursing unit on September 23, 2025, at 10:25 AM revealed that entering and exiting the unit was possible by either waving a hand over a wall sensor or by using a push-bar on the door.Clinical record review for Resident 4 revealed nursing documentation dated July 17, 2025, at 3:09 PM that Resident 4 was ambulating on the unit with her walker stating, I'm not staying tonight; that she was exit-seeking, and that redirection was effective for short intervals.Nursing documentation dated July 18, 2025, at 12:52 PM revealed that Resident 4 was wandering and attempting to elope.Nursing documentation dated July 20, 2025, at 3:11 PM revealed that Resident 4 attempted to exit the nursing unit. Review of a fall incident investigation dated July 26, 2025, at 4:15 AM revealed that staff identified, Resident is new to SNF (skilled nursing facility). She is independent in the facility and wanders all around but is severely cognitively impaired Nursing documentation dated August 3, 2025, at 3:19 PM revealed that a licensed practical nurse notified the writer that Resident 4 left the facility and could not be redirected to return to the facility. Interview with the Nursing Home Administrator and the Director of Nursing on September 24, 2025, at 2:00 PM revealed that the facility interdisciplinary team did not have an incident investigation or report to the Department details related to the events of August 3, 2025, for Resident 4 because staff did not recognize the incident as elopement given staff were with Resident 4 when she left the building. The interview indicated that the facility did not recognize the area outside the [NAME] nursing unit as having potential accident hazards (an unsafe area). Resident 4's wander guard alerted staff of her attempt to exit when she reached the facility's front doors. Nursing documentation dated August 4, 2025, at 1:25 PM revealed that the facility moved Resident 4 to a second-floor nursing unit room due to safety concerns.Observation of the lobby area outside the [NAME] nursing unit on September 26, 2025, at 9:52 AM revealed no impediments that would prevent a confused and wandering resident from leaving the unit, making a left hand turn into a long hallway past the main kitchen area, to the unlocked and unmonitored doors of the personal care facility attached to the nursing care facility, and exiting an unlocked and unmonitored door to the left of the personal care facility entrance, that allowed sidewalk access to a parking area.Observation of the facility's open cafe area outside the main kitchen on September 26, 2025, at 10:15 AM revealed a male individual ambulating towards the personal care facility. Interview with the male individual indicated that he resided in the personal care section of the building but walked back and forth between the personal care facility and the long-term care facility as desired.Interview with Employee 6 (dietary manager) on September 26, 2025, at 9:54 AM confirmed that she was aware of the male individual in the area of the cafe. Employee 6 walked with the surveyor through the hallway, into the personal care facility, and to the unlocked and unmonitored door to confirm unfettered exit from the long-term care facility to a parking area.Interview and observation with Employee 12 (social services) on September 26, 2025, at 9:59 AM confirmed the observation of unmonitored and unlocked egress to the personal care facility and potential to exit the building to a parking area from an unlocked and unmonitored door. The surveyor reviewed the above environmental safety concerns regarding the unmonitored and unlocked doors during an interview with the Nursing Home Administrator on September 26, 2025, at 10:20 AM. The interview confirmed that there is another resident who resided on a first-floor nursing unit with a wander guard (who had known wandering behaviors) that the facility would try to relocate to a second-floor nursing unit to ensure that an attempt to exit the building would lockdown the elevator and prevent an elopement from the building.The facility failed to identify and implement interventions to correct all potential accident hazards for a resident with elopement behaviors. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devicesPreviously cited deficiency 8/30/24 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, who utilize a lift, catheter care, medication administration, transmission based precautions, intravenous therapy, and dressing changes for four of four employees reviewed for competencies (Employees 2, 3, 4, and 5). Findings include: A review of the facility documentation revealed that the facility had a total of 87 residents receiving medications, 25 residents that utilize lifts, five residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine), 12 residents with dressing changes, 23 residents with enhanced barrier precautions, one resident with intravenous therapy (technique that delivers fluids, medications, and nutrients directly into a patient's bloodstream through a vein), and one resident with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube). A request for nursing staff competencies for the above-mentioned areas revealed the facility was unable to provide any competencies for Employees 2 and 3 (licensed practical nurses) and Employees 4 and 5 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Director of Nursing on September 25, 2025, at 1:07 PM. They confirmed the facility could provide no documentation that ensured Employees 2, 3, 4, and 5 had specific competencies and skill sets to care for the residents needs listed above. 483.25(c)(1)-(3) Increase/prevent Decrease in ROM/mobilityPreviously cited deficiency 8/30/2024 28 Pa. Code 201.20 (a) Staff Development

Based on clinical record review and staff interview, it was determined that the facility failed to provide timely notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 93 and 57).Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055) is issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Key elements of compliance with the provision of the notice include that the facility notified an eligible resident in writing of the items and services which are/are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services as soon as reasonably possible when a change in coverage occurs. The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review for Resident 93 revealed census information that the facility provided services primarily paid for by Medicare A starting [DATE]. Resident 93's Medicare payment for services ended [DATE]. Resident 93 discharged out of the facility on [DATE]. Physical therapy documentation dated [DATE], at 11:59 AM indicated that therapy was provided; and that Resident 93 was scheduled for discharge on [DATE]. Physical therapy documentation dated [DATE], at 12:26 PM revealed that Resident 93 had no further skilled therapy needs and would discharge home the next day with home health services. The surveyor reviewed concerns that the facility did not provide a CMS-10123 notice to Resident 93 two days before the discontinuation of her Medicare A services during an interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 2:00 PM. The interview confirmed that Resident 93 did not leave the facility against medical advice (AMA). Clinical record review for Resident 57 revealed that the facility admitted her on [DATE], to receive services primarily paid for by Medicare A. Review of census information for Resident 57 revealed that the last day of Medicare A payment for services was [DATE]. Resident 57 began private payment for services beginning [DATE]. Resident 57 remained in the facility until she expired on [DATE]. Review of a CMS-10123 form for Resident 57 confirmed that Medicare A coverage for services ended [DATE]. The notice included documentation that facility staff discussed the notice and change in payment coverage with the responsible party on [DATE]. Resident 57's responsible party signed the notice on [DATE] Review of a CMS-10055 form for Resident 57 indicated that beginning on [DATE], Resident 57 would be responsible for an estimated cost per day. Resident 57's responsible party signed the notice on [DATE] (one day before). The notice did not include documentation that facility staff attempted to discuss the change in payment for services that included the estimated cost per day with Resident 57's responsible party as soon as reasonably possible when a change in coverage was anticipated (e.g., during the discussion on [DATE]). The surveyor reviewed the above concerns regarding Resident 57's CMS-10055 notice with the Nursing Home Administrator on [DATE], at 10:09 AM. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of select facility policy and procedures, observations, and staff interview, it was determined that the facility failed to ensure a resident's rights to secure and confidential personal and medical information in the facility's main lobby for one of one resident reviewed for privacy concerns (Main Lobby Area; Resident 94). Findings include: A review of the facility policy titled, Confidentiality, last reviewed without changes on April 7, 2025, revealed a policy statement to ensure that a resident's confidential health information is protected from use or disclosure that is in violation of the Health Insurance Portability and Accountability Act (HIPAA) or other applicable federal or state requirements. Further review of the policy revealed that an individual's protected health information (PHI) should not be discussed with those not entitled to the information. Observation of the main lobby of the facility on September 26, 2025, at 9:30 AM revealed a binder titled Department of Health Surveys. The binder contained the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binder revealed that the facility placed the full health survey and complaint survey results in the binder. Further review of the binder revealed a complaint deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a complaint investigation on June 12, 2025. The letter noted the name and associated specific resident identifier for Resident 94. The facility failed to ensure Resident 94's right to privacy of their personal and medical information. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 26, 2025, at 1:35 PM. 28 Pa. Code: 201.18(e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to develop baseline care plans within 48 hours of admission for two of 18 residents reviewed (Residents 5 and 33).Findings include: Clinical record review for Resident 5 revealed that the facility admitted him on September 5, 2025. Hospital transfer documentation dated September 5, 2025, revealed that his medication regime included the administration of Warfarin (anticoagulant medication used to prevent and treat blood clots) daily at 3:00 PM. Nursing documentation dated September 5, 2025, at 5:00 PM revealed that Resident 5 arrived at the facility after hospitalization for left lower extremity cellulitis (common bacterial infection of the layers of the skin) from a venous stasis ulcer (wound that occurs due to poor blood flow in the veins). Resident 5's medication administration record (MAR, electronic documentation of the administration of medications) dated September 2025 revealed that Resident 5 received the Warfarin medication on September 6, 2025, at 9:00 PM. Review of Resident 5's baseline care plan (developed by the facility within 48 hours of admission) did not include the use or complications of anticoagulant therapy. A plan of care (initiated September 13, 2025, one week after Resident 5's admission) noted that Resident 5 was on anticoagulant therapy. Review of diagnoses listed for Resident 5 revealed that he was diagnosed with prediabetes (higher than normal blood sugar assessments, but not high enough to meet the criteria for a diabetes diagnosis) on his admission date of September 5, 2025. Nursing documentation dated September 8, 2025, at 6:01 PM revealed that the practitioner provided an order to perform an Accu-Chek assessment (glucose testing of a drop of blood obtained from a finger prick) at breakfast and supper and implement a sliding scale of insulin administration doses (the hormone insulin is injected in dosages based on the blood sugar level of the Accu-Chek assessment). An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], noted that Resident 5 received insulin injections on three of the seven days reviewed. Review of the care plans developed by the facility for Resident 5 revealed no evidence that staff included Resident 5's use of insulin for his elevated blood sugars. The surveyor reviewed the above concerns regarding Resident 5's care plan development during an interview with the Nursing Home Administrator and the Director of Nursing on September 25, 2025, at 2:00 PM. Clinical record review for Resident 33 revealed hospital documentation dated August 12, 2025, by an infectious disease practitioner that indicated Resident 33 was admitted to the hospital on [DATE] for a pressure ulcer (wound that progresses through several stages from a simple break in the skin to depths that may expose bone or muscle) on her sacrum (tailbone) that presented with sacral osteomyelitis (infection that spread to the bone). The treatment recommendations for Resident 33 included the use of the intravenous antibiotic, Unasyn. Nursing documentation dated August 13, 2025, at 5:13 PM revealed that the facility admitted Resident 33 with a PICC line (peripherally inserted central catheter, a long, thin tube that's inserted through a vein in your arm and passed to the larger veins near your heart); and that she would receive the antibiotic, Unasyn. A medical diagnoses list for Resident 33 dated August 13, 2025, included osteomyelitis of the sacral region and pressure ulcer of the sacral region. admission nursing documentation dated August 13, 2025, at 5:13 PM assessed a pressure ulcer, Stage 4 (full thickness skin and tissue loss with exposed bone, tendon, or muscle) to Resident 33's sacrum that measured 13 cm (centimeters) by 7 cm by 3 cm. Review of Resident 33's care plans revealed that the facility did not initiate a plan of care to address interventions implemented for her skin integrity impairment (Stage 4 sacral pressure ulcer) until August 28, 2025 (more than two weeks after her admission). The plans of care available in Resident 33's medical record contained no plan of care to address the care and potential complications of a PICC site. Interview with the Director of Nursing on September 26, 2025, at 11:13 AM confirmed that Resident 33's baseline plan of care did not address the care and services for her Stage 4 pressure ulcer or the care and potential complications for her PICC line intravenous access. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding wound assessment for one of three residents reviewed for skin concerns (Resident 58). Findings include: Clinical record review for Resident 58 revealed a diagnosis list that included dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons). Further clinical record review for Resident 58 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 28, 2025, that noted facility staff assessed the resident as rarely/never understood. A review of the task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 58 revealed that staff were to apply a moisture barrier to the buttocks with incontinence care. Resident 58's care plans revealed that the resident was at risk for altered skin integrity and the resident had bladder incontinence related to activity intolerance. Braden Score documentation for Resident 58 dated June 3, 2025, at 6:18 PM revealed a Braden Score of 12.0 (a clinical tool used to assess the risk of developing pressure ulcers; a score of 12 indicates a high risk). A skin/wound note dated June 6, 2025, at 2:46 AM revealed that Resident 58 is developing MASD (moisture associated skin damage) on the sacrum. A fax was sent to the medical provider to update. Clinical documentation for Resident 58 dated June 6, 2025, at 2:47 AM revealed a skin check note that indicated a new skin issue on the middle sacrum that was inquired in-house. The skin issue was documented as MASD and was measured at 1.3 centimeters (cm) in width and 0.9 centimeters in depth. It was noted as, New Skin Issue. A skin/wound note for Resident 58 dated June 6, 2025, at 11:03 AM revealed documentation that the resident had Sacral MASD noted measuring 1.5 cm x 0.5 cm, treatment in place. A health status note for Resident 58 dated June 23, 2025, at 2:24 PM revealed that a three day bowel and bladder diary noted the resident is incontinent of bowel and bladder. Skin check documentation for Resident 58 revealed that the resident had MASD; however, the documentation noted Skin issue has not been evaluated, and staff continued to document, Wound is new, for the following dates: June 12, 2025, at 7:28 PMJune 19, 2025, at 8:34 PMJune 26, 2025, at 4:34 PM July 3, 2025, at 5:13 PMJuly 10, 2025, at 4:25 PMJuly 17, 2025, at 9:34 AMJuly 24, 2025, at 7:21 PMJuly 31, 2025, at 4:11 PM August 7, 2025, at 6:06 PMAugust 14, 2025, at 4:04 PMAugust 21, 2025, at 6:07 PMAugust 28, 2025, at 3:45 PM September 4, 2025, at 4:36 PMSeptember 11, 2025, at 3:48 PMSeptember 18, 2025, at 3:59 PMSeptember 25, 2025, at 3:30 PM A long term care evaluation for Resident 58 dated August 28, 2025, at 9:28 AM revealed that Z-guard (a topical medication to protect the skin) continues related to incontinence. The documentation revealed that the resident had MASD; however, the documentation noted Skin issue has not been evaluated, and staff continued to document the wound as new. Further clinical record review for Resident 58 revealed no evidence that the resident's MASD was routinely or comprehensively assessed after the initial assessment on June 6, 2025, to determine if the wound was improving or worsening. An interview with the Director of Nursing on September 26, 2025, at 2:10 PM revealed the facility could provide no further evidence that Resident 58's MASD was routinely or comprehensively assessed. 483.25 Quality of CarePreviously cited deficiency 8/30/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement treatment and services to promote the healing of pressure ulcers for one of three residents reviewed for pressure ulcer concerns (Resident 63).Findings include: The policy entitled Pressure Injury Treatment Protocol, last reviewed without changes April 7, 2025, revealed the purpose of this procedure is to provide guidelines for the care of existing pressure injuries. All pressure injuries will be assessed every week and as needed using the 52 Week Wound Assessment. If the wound does not improve in 14 days, the facility is to notify the physician, re-evaluate nutritional support, offloading or redistribution devices, and advanced wound product changes. Clinical record review revealed the facility admitted Resident 63 on April 15, 2025. Nursing documentation dated April 15, 2025, at 5:08 PM revealed Resident 63 was admitted with a Stage 2 (partial thickness loss of skin with exposed dermis) on her sacrum, measuring 2 centimeters (cm) by 0.5 cm by 0.1 cm. Further review of Resident 63's clinical record revealed the following assessments of Resident 63's sacrum completed by a wound care specialist: April 17, 2025, Stage 2 measuring 3.6 cm by 1.5 cm by 0.1 cm April 24, 2025, Stage 2 measuring 3.3 cm by 1.4 cm by 0.1 cm May 1, 2025, the wound care specialist rescheduled Resident 63's appointment May 8, 2025, the wound care specialist rescheduled Resident 63's appointment Resident 63's wound was not assessed again until May 16, 2025, when the wound care specialist noted the open area on Resident 63's sacrum was now a Stage 3 (full thickness skin loss, exposing the fatty tissue beneath) pressure ulcer, measuring 1.2 cm by 0.8 cm, by 0.3 cm There was no assessment of Resident 63's sacral pressure ulcer from April 24 to May 16, 2025 (three weeks), going from a Stage 2 to Stage 3 pressure ulcer. Interview with the Director of Nursing on September 26, 2026, at 1:49 PM confirmed Resident 63's pressure ulcer was not assessed at least weekly, with an evaluation including the date observed, location and staging, and size. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, and family and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for one of two residents reviewed for range of motion concerns (Resident 7).Findings include: Interview with Resident 7's family on September 23, 2025, at 10:23 AM revealed Resident 7 was struggling to walk now. She stated that Resident 7 has been unsteady and has a difficult time lifting his right foot. Clinical record review revealed the facility admitted Resident 7 on October 18, 2022. Review of Resident 7's MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated April 3, 2025, revealed Resident 7 had no limitations to his range of motion, and was able to walk 150 feet with supervision of staff, or touching assistance. Review of a therapy referral form dated June 7, 2025, revealed Resident 7's wife requested a physical therapy screen due to his shuffling and unsteady gait, and difficulty with transfers. There was an undated note at the bottom of the therapy referral form indicating no skilled therapy needs, no change in function. Resident 7's next MDS dated [DATE], revealed staff now assessed Resident 7 as having upper extremity limitations to his one side, and needed partial to moderate staff assistance to walk 150 feet. Review of a therapy referral form dated June 30, 2025, revealed after staff interview, it was determined that Resident 7 is partial to moderate assistance with toileting hygiene, substantial assistance with upper body dressing, and dependent on staff assistance for lower body dressing. A therapy referral was placed for the significant decline in Resident 7's activities of daily living functional abilities. Review of Resident 7's occupational therapy documentation revealed an evaluation dated July 17, 2025, due to the decline in his activities of daily living. Resident 7 and family were present for the evaluation and stated no change in Resident 7's functional status indicating Resident 7 frequently has bad days. Resident 7's family reported shaking in Resident 7's lower right extremity with difficulty lifting his foot during ambulation. Occupational therapy noted no further needs identified for Resident 7 and made a referral to physical therapy for ambulation training. Review of physical therapy documentation revealed they did not assess Resident 7 until August 14, 2025, and he remained on caseload until September 1, 2025. Review of physical therapy's discharge recommendations dated September 1, 2025, revealed Resident 7 is to continue ambulation via restorative nursing program as nursing staff have been doing. A restorative ambulation program was established. Physical therapy revealed Resident 7's prognosis to maintain his current level of function would be excellent with consistent staff support and participation in restorative nursing program. The facility was unable to provide any documentation of a restorative nursing program for Resident 7's decline in ambulation. There was no evidence of the restorative nursing ambulation program referenced by physical therapy Interview with the Nursing Home Administrator and Director of Nursing on September 26, 2025, at 1:39 PM confirmed the delay in Resident 7 receiving therapy services and no evidence of a restorative nursing ambulation program for Resident 7. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel continence for one of two residents reviewed for incontinence (Resident 7).Findings Clinical record review revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff assessed Resident 7 as continent of his bowel. Further review of Resident 7's clinical record revealed an MDS assessment completed on April 3, 2025, noting staff assessed Resident 7 as now occasionally incontinent of bowel, and a significant change MDS completed on June 30, 2025, revealed staff assessed Resident 7's bowel continence declining to now being frequently incontinent of bowel. Interview with the Director of Nursing and Nursing Home Administrator on September 26, 2025, at 1:37 PM revealed the facility did not have a policy addressing bowel continence. Review of Resident 7's plan of care for toilet use initiated February 6, 2023, revealed Resident 7 requires assistance of one staff for his toileting needs. Further review of Resident 7's clinical record revealed a bowel and bladder three-day observation record for April 17, 18, and 19, 2025 and again on July 4, 5, and 6, 2025. There was no documented evidence that staff reviewed Resident 7's observation records to implement individualized interventions to promote bowel continence. Review of Resident 7's task documentation revealed on April 22, 2025, staff were to offer to assist Resident 7 to the bathroom daily at midnight, 3:00 AM, after breakfast, and at 5:00 PM. Review of task documentation dated July 17, 2025, revealed staff were now to only offer to assist Resident 7 to the bathroom at midnight and 3:00 AM The facility failed to assess and implement individualized interventions to promote Resident 7's bowel continence. The findings were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on September 26, 2025, at 1:30 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure medication security for two of 18 residents reviewed (Residents 4 and 62).Findings include: The facility policy entitled, Discarding and Destroying Medications, last reviewed without changes on April 7, 2025, revealed that non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Should the facility contract with a DEA-registered collector, controlled substances may be disposed of in an authorized collection receptacle located at the facility. Both controlled and non-controlled substances may be disposed of in the collection receptacle. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the steps include mixing the medication (either liquid or solid) with an undesirable substance (to include sand, coffee grounds, kitty litter, or other absorbent materials). Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. Dispose with solid waste (i.e. regular trash) in the presence of two witnesses. Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room. Clinical record review for Resident 4 revealed nursing documentation created August 21, 2025, at 9:51 AM for an effective date of August 20, 2025, at 9:45 AM that staff found Resident 4 in her room taking two pills. The documentation indicated that the nurse did not know where the medication came from or how many pills Resident 4 took before discovered by staff. Resident 4 (who had the diagnosis of dementia and exhibited cognitive deficits) stated that she took a couple other pills. The writer indicated that they did not administer morning medications and did not know what medications Resident 4 had. Incident note documentation dated August 22, 2025, at 12:32 PM revealed that the writer was notified on August 21, 2025, at 4:00 PM that staff observed Resident 4 with unknown medications in her possession and an incident report was completed. It was reported that this incident occurred on August 20, 2025, at 12:00 PM and no documentation was completed. It was unclear if she ingested any of the medications or not. The medications were removed and disposed of by the unit licensed practical nurse. Review of the facility's incident investigation dated August 20, 2025, at 12:00 PM revealed notes dated August 22, 2025, that the interdisciplinary team discussed the incident and Whole house education started for all nursing staff to never leave medications unattended on the medication cart or in resident rooms. Interview with the Director of Nursing on September 25, 2025, at 11:03 AM revealed that the facility did not have evidence of completion of education with all house nursing staff regarding medication security. Observation of Resident 62's room on September 24, 2025, at 9:17 AM revealed a privately paid caregiver (Employee 7) at his bedside. Employee 7 stated that she observed a medication tablet on Resident 62's floor when she entered his room this morning, that she reported it to the nurse on the unit, and that the nurse on the unit disposed of it in the garbage receptacle in Resident 62's room. Observation of the area around Resident 62's room trash receptacle revealed an oblong, ruddy-colored, tablet on the floor near the garbage receptacle. Observation and interview with Employee 8 (licensed practical nurse) on September 24, 2025, at 9:46 AM confirmed that Employee 7 pointed out the tablet to her that morning and she disposed of it in the garbage in Resident 62's room. When compared to house stock Omeprazole (medication used to decrease stomach acid), it was determined that the tablet in Resident 62's room was delayed-release Omeprazole 20 milligrams (mg). Clinical record review for Resident 62 revealed no physician orders for staff to administer Omeprazole to Resident 62. The surveyor reviewed the above concerns regarding medication security with the Nursing Home Administrator on September 25, 2025, at 10:15 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area.Findings include: Observation of the facility's main kitchen on September 23, 2205, at 9:03 AM with Employee 6, dietary manager, revealed the following: The wall of the dishwashing area contained multiple black colored, winged, smaller insects. At least four were observed on the wall. A concurrent interview with Employee 6 revealed that these insects have been present for at least one and a half weeks and the facility placed traps to help remedy the insects. Further observation of the main part of the kitchen revealed multiple additional black colored, winged insects located on the ceiling next to a vent. The ceiling area adjacent to the vent had unidentified splash stains. A large spider was observed walking across the floor in the area that held the heated meal delivery carts and proceeded to enter a floor drain. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 24, 2025, at 2:00 PM. Pest control documentation dated May 31, 2025, June 30, 2025, and July 9, 2025, revealed that pest management provided services to the facility for general pest control - maintenance, exterior insect perimeter treatment - maintenance, and bioremediation. This pest control documentation revealed no evidence that the pest control service was notified of the winged insects in the facility's main kitchen. Pest control documentation dated September 24, 2025, at 5:38 PM revealed a pest management visit that noted some phorid flies and fruit flies around the drains due to grease and food build up. Pest management treated around the drains and drain lines to help resolve the current issue and prevent future problems from occurring. The facility failed to maintain an effective pest control program so that the facility's main kitchen is free of pests. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(3) Management

Based on observation, review of select facility policies and procedures, clinical record review, and staff and family interview, it was determined that the facility failed to assess and implement interventions to prevent dehydration for two of 19 sampled residents (Residents 42 and 87). Findings include: The facility policy entitled, "Hydration Protocol," last reviewed August 2012, revealed that residents will be assessed to determine if they are at high risk for dehydration. Interventions will be implemented to assure adequate hydration. Residents identified as high risk for dehydration will be assessed and monitored to identify appropriate care plan interventions to maintain adequate hydration. A Hydration Risk assessment may be completed at any time staff assesses resident status to indicate hydration status may be at risk. Any resident identified as being at risk for dehydration through nursing and/or dietitian assessments will be placed on the Diakon Hydration Protocol. Risk factors include limited intake. The resident's care plan should indicate that the resident has been placed on the Hydration Protocol. The Hydration Protocol documentation form will serve as the document for the care plan interventions. A Hydration Protocol documentation form will be initiated. The dietitian or licensed nurse will calculate the fluid requirements as part of each resident's nutritional assessment using the 30 cc/kg (cubic centimeters per kilogram) body weight formula. All fluid intakes will be documented on Care Tracker. All disciplines will input intake of any fluids given by them in to the Care Tracker. The nurse will run a Care Alert report at the end of each shift and document a clinical assessment in the Diakon Hydration Protocol form each 24 hour period. At the beginning of the night shift, a Care Tracker report will be run for the prior three shifts and used to compare the resident's intake with target fluid requirements to determine if the target was met. If the target was not met, the resident will be assessed by the registered nurse or licensed practical nurse for signs and symptoms of dehydration. The assessment will be documented on the Hydration Protocol form. All residents identified to be at risk will have a raindrop on a card placed at their name on their door and on their wheelchair. Clinical record review for Resident 42 revealed that the facility admitted her on October 30, 2012, following a hospitalization from [DATE] through 30, 2012. Review of the hospitalization discharge summary dated October 29, 2012, revealed that laboratory testing completed October 30, 2012, reflected a sodium level within normal limits at 138 milliequivalents per liter (mEq/L), potassium within normal limits at 3.3 mEq/L, chloride within normal limits at 102 mEq/L, BUN (blood urea nitrogen, waste product in the blood, when elevated, could be an indicator of dehydration) within normal limits at 11 milligrams per deciliter (mg/dL), hemoglobin (protein that carries oxygen in the blood) low at 10.7 grams per deciliter (gr/dL), and hematocrit (volume percentage of red blood cells in the blood) low at 31.5 percent. A nutritional assessment completed by the dietitian on November 1, 2012, based Resident 42's fluid needs at 1710 cc per day based on 30 cc per kilogram of body weight. Review of Resident 42's fluid intakes for the month of November 2012 revealed that the facility documented an average daily fluid intake of 939 cc for November 2012. There was no indication that staff placed Resident 42 on the Hydration Protocol, that the dietitian or nursing staff implemented changes to Resident 42's plan of care targeted at her risk for dehydration, or notified Resident 42's physician of her failure to meet her fluid needs. Review of Resident 42's fluid intakes from December 28, 2012, through January 11, 2013, revealed the following totals: December 28, 2012, 1230 cc December 29, 2012, 1050 cc December 30, 2012, 1585 cc December 31, 2012, 1235 cc January 1, 2013, 1290 cc January 2, 2013, 1325 cc January 3, 2013, 940 cc January 4, 2013, 150 cc January 5, 2013, 700 cc January 6, 2013, 1145 cc January 7, 2013, 570 cc January 8, 2013, 1185 cc January 9, 2013, 715 cc January 10, 2013, 505 cc January 11, 2013, 185 cc Resident 42's three day fluid intake averages reflected a further decline in January 2013 as follows: 3 Day Average December 28 - 30, 2012, 1288 cc 3 Day Average December 29 - 31, 2012, 1290 cc 3 Day Average December 30, 2012 - January 1, 2013, 1370 cc 3 Day Average December 31, 2012 - January 2, 2013, 1283 cc 3 Day Average January 1 - 3, 2013, 1185 cc 3 Day Average January 2 - 4, 2013, 805 cc 3 Day Average January 3 - 5, 2013, 597 cc 3 Day Average January 4 - 6, 2013, 665 cc 3 Day Average January 5 - 7, 2013, 805 cc 3 Day Average January 6 - 8, 2013, 967 cc 3 Day Average January 7 - 9, 2013, 823 cc 3 Day Average January 8 - 10, 2013, 802 cc Nursing documentation dated January 4, 2013, at 2:27 PM revealed that Resident 42 had nausea and vomiting on dayshift for which the physician was called. Although Resident 42 only consumed 150 cc of fluid that day, had symptoms of nausea and vomiting, and reflected less than required fluid intakes since her admission, there was no indication that staff completed an assessment for signs and symptoms of dehydration. Nursing documentation dated January 11, 2013, at 10:42 PM revealed that Resident 42 was unable to swallow anything, and did not drink any liquids. Staff notified Resident 42's physician who ordered the initiation of intravenous fluids and laboratory testing for the morning. Laboratory reports dated January 12, 2013, at 9:10 AM revealed a critically high BUN at 63 mg/dL, high sodium at 156 mEq/L, critically high chloride at 120 mEq/L, hemoglobin at 15.7 gr/dL (normal 11.5 to 16.1 gr/dL), and hematocrit of 47.7 percent (normal range 34.5 to 47.8 percent). A physician's progress note dated January 18, 2013, noted that Resident 42's dehydration was corrected with intravenous fluids. Observation of Resident 42's room on April 23, 2013, at 10:44 AM revealed no raindrop by her name, on her door, as per the facility policy. Interviews with the Nursing Home Administrator and Director of Nursing on April 25, 2013, at 2:00 PM and with the Director of Nursing on April 26, 2013, at 11:30 AM confirmed that the facility had no evidence that Resident 42 was identified as high risk for dehydration, had a Hydration Risk assessment completed at any time, or was on the Diakon Hydration Protocol. Although Resident 42's estimated fluid needs were not met, she was not assessed by the registered nurse or licensed practical nurse for signs and symptoms of dehydration. Resident 42 also did not have a raindrop on the card placed at her name on her door. Clinical record review for Resident 87 revealed that on January 4, 2013, the resident had an appointment for tooth extraction. Resident 87 returned from the dental appointment at 12:30 PM. Clinical record review for Resident 87 revealed that he had 21 teeth extracted at that time. Physician orders [REDACTED]. No drinking from a straw, soda bottle or sports bottle, and no spitting. Resident 87 was also to rinse his mouth with one quarter teaspoon of salt dissolved in warm water three times a day after meals. Another physician's orders [REDACTED]. A nutritional assessment completed by the dietitian on October 22, 2012, based Resident 87's fluid needs at 1950 cc per day based on 30 cc per kilogram of body weight. Review of Resident 87's fluid intakes for January 4, 2013 through January 10, 2013 revealed that the facility documented an average daily fluid intake of 805 cc. There is no indication that staff placed Resident 87 on the Hydration Protocol, that the dietitian or nursing staff implemented changes to Resident 87's plan of care targeted at his risk for dehydration, or notified Resident 87's physician of his failure to meet his fluid needs. On January 10, 2013, the facility completed a Quarterly Nutrition Review and notified Resident 87's physician of his poor intakes. The facility recommended intravenous fluids or a tube feeding to supplement Resident 87's poor oral intakes until his mouth was healed Nursing documentation dated January 10, 2013, also revealed that nursing staff notified Resident 87's physician via a fax that Resident 87 was very lethargic, had poor skin turgor, and that he had poor oral intakes. Review of Resident 87's fluid intakes from January 4, 2013, through January 10, 2013, revealed the following totals: January 4, 2013, 360 cc January 5, 2013, 800cc January 6, 2013, 1300 cc January 7, 2013, 690 cc January 8, 2013, 900 cc January 9, 2013, 780 cc January 10, 2013, 0 cc Review of nursing documentation dated January 5, 2013, revealed that Resident 87 was non-compliant with his mouth rinses and allowing staff to perform the rinses. There is no evidence that Resident 87's dentist was made aware of Resident 87's refusal of mouth care at that time. Nursing documentation dated January 6, 2013, indicated that Resident 87 continued to be non-compliant with his salt water rinses to his mouth and "tolerated poorly." There is no evidence that Resident 87's dentist was made aware Resident 87's refusal of mouth care at that time. Nursing documentation dated January 7, 2013, indicated that Resident 87 was non-compliant with mouth rinses and that he had difficulty eating and drinking. There is no evidence in Resident 87's clinical record that his dentist or primary physician was made aware of Resident 87's continued noncompliance with mouth care or his increased difficulty with eating and drinking. Nursing documentation dated January 10, 2013, at 4:55 PM revealed that Resident 87 had a blank stare and "not easily responding to sternal rub" (procedure used to determine mental alertness by placing a hand firmly on the chest and giving a brisk rub). Ongoing review of nursing documentation dated January 10, 2013, at 4:55 PM revealed that Resident 87 was "not swallowing liquids, letting them run out of his mouth." Resident 87 was also nonverbal, had poor skin turgor, and was "more lethargic than normal baseline." Nursing documentation dated January 10, 2013, at 5:06 PM revealed that Resident 87 had blood in his mouth from his teeth extraction on January 4, 2013. Nursing documentation dated January 10, 2013, at 9:03 PM revealed that, "per ER (emergency room ), resident (87) admitted with acute or [MEDICAL CONDITION]." Clinical record review revealed that the facility readmitted Resident 87 on January 17, 2013, following a hospitalization from [DATE] through January 17, 2013. Review of the hospital admission records dated January 10, 2013, revealed that Resident 87 presented to the hospital with acute or [MEDICAL CONDITION] and [MEDICAL CONDITION] (elevated sodium levels) secondary to profound dehydration. Laboratory testing completed on January 10, 2013, revealed an abnormal sodium level of 168 mEq/L (normal range 135 to 145 mEq/L), and an abnormal BUN of 69 mg/dL (normal range 6 to 25 mg/dL). Resident 87 was given a [MEDICATION NAME] (a rapidly absorbed intravenous injection) at 500 cc normal saline followed by D5 solution (sugar solution) immediately at the hospital. Interview with Resident 87's son April 25, 2013, at 1:00 PM revealed that on January 10, 2013, Resident 87 was admitted to the hospital and observed by family members to have dry chapped lips and dried blood caked in his mouth. Interview with the Director of Nursing and Administrator on April 26, 2013, at 2:30 PM confirmed that the resident was admitted to the hospital for dehydration. 28 Pa. Code 28 201.18 (b)(1) Management. Previously cited 5/17/12. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 5/17/12. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 5/17/12 and 2/19/13.

Based on observation, clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to assess, monitor, and provide interventions to prevent skin breakdown for two of 19 sampled residents (Residents 48 and 23). Findings include:The policy entitled "Pressure Ulcer Prevention Protocol," last reviewed September 2010, revealed that the facility would ensure that a resident who enters the facility without pressure sores (damage to the skin due to pressure) does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Staff will complete a Braden Scale assessment tool (a scale for determining a resident's risk of developing a pressure sore) on all residents, provide appropriate preventive measures, and obtain a physician's orders [REDACTED]. The facility policy entitled "Restorative Nursing Splint and Brace Program," last reviewed September 2010, revealed that the nursing staff initiates this program when a resident cannot independently apply or remove a splint or brace. The policy revealed that the nursing staff check the resident's skin every two hours where the splint or brace contacts the skin to prevent pinching or pressure of the skin. The facility documents the program in the resident's care plan and updates the care plan as needed. Nursing staff document the resident's splint and brace program in the electronic documentation system. Clinical record review for Resident 48 revealed nursing documentation dated May 3, 2011, that indicated the resident fell at the facility fractured her right hip and required hospitalization . Upon return from the acute care hospital on May 7, 2011, the staff assessed Resident 48's pressure ulcer risk using the "Braden Scale," obtaining a score of 19 (indicating that she was at no risk for pressure ulcers) despite her non-weight bearing status. There was no documentation on Resident 48's care plan, dated May 7, 2011, indicating any interventions for the prevention of pressure sores. On May 13, 2011, the resident's care plan was rewritten and the staff identified Resident 48 as having a significant change in status (decline or improvement in resident status) with a potential for skin breakdown due to decreased mobility and incontinence (inability to control urine or bowels) due to a [MEDICAL CONDITION] and dementia. On May 14, 2011, the staff assessed Resident 48 using the "Braden Scale" again, obtaining a score of 19, indicating that she was not at risk for pressure sores. The nursing documentation dated May 17, 2011, indicated that staff noted a Stage II blister (partial thickness loss of skin layers involving epidermis and/or dermis that presents clinically as an abrasion, blister, scab or shallow crater) measuring 4.0 centimeters (cm) long and 2.7 cm wide, and was dark red in color. The staff contacted Resident 48's physician who ordered the right heel to be elevated off of the bed with a pillow. According to Resident 48's "Wound and Skin Care Weekly Flow Sheet," the Stage II pressure ulcer continued to increase in size with the following measurements: May 19, 2011, 4.0 cm long by 4.0 cm wide May 26, 2011, 4.0 cm long by 5.2 cm wide June 2, 2011, 4.0 cm long by 5.2 cm wide June 9, 2011, 5.4 cm long by 5.2 cm wide During the initial tour of the facility on June 7, 2011, at 10:30 AM, the surveyor observed Resident 48 with a heels up cushion (a cushion used to keep the heels off of the bed) under her legs with her heels resting on the bed. Observation of Resident 48 on June 8, 2011, revealed that she was lying in bed with the heels up cushion in place and her heels were again resting on the bed. A physician's orders [REDACTED]. Observation of Resident 48 on June 9, 2011, at 8:30 AM, revealed that she was lying in bed with the heels up cushion in place and her heels resting on the bed. Observation of Resident 48 on June 10, 2011, at 9:30 AM, revealed that she was lying in bed with her heels resting on the pillow. An interview with Employee 3 (Licensed Practical Nurse) who identified herself as the Charge Nurse in care of Resident 48 on June 10, 2011, at 2:05 PM, revealed that she was not aware of which pressure-relieving measures should be in place while Resident 48 was in or out of bed. An interview with the Nursing Home Administrator, Employee 1 (Registered Nurse Assessment Coordinator, RNAC), and Employee 2 (RNAC) on June 10, 2011, at 11:15 AM, revealed that Resident 48 was at a high risk for developing pressure ulcers since her return from the hospital on May 7, 2011, due to her decreased mobility. The interview revealed that nursing staff had completed the Braden Scale Assessments inaccurately. The staff failed to include measures to prevent skin breakdown on the care plan. The facility failed to provide interventions to prevent a pressure ulcer and implement physician ordered interventions resulting in the development of a Stage II pressure ulcer on Resident 48's heel, which continued to increase in size. The clinical record review for Resident 23 revealed a Significant Change Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated April 7, 2011, that indicated Resident 23 required extensive assistance (the resident is involved in the activity but the staff provide weight-bearing support) to dress. A physician's orders [REDACTED]. The nursing documentation dated May 17, 2011, revealed that Resident 23 reported to the nursing staff that she had pain in her left lower extremity (lower limb of the body). The nursing staff assessed Resident 23's left foot and observed three plus, [MEDICAL CONDITION] (a grading method for swelling of the foot, one plus is rated as the lowest swelling, and four plus is rated as the most swelling) at the top of the brace. The nursing staff also observed a Stage II (partial thickness loss of the skin) pressure ulcer at the outer aspect of her foot. The nursing staff assessed Resident 23 as having redness on her left heel and two reddened areas on her left lower leg. Resident 23's physician discontinued use of the brace. Review of Resident 23's clinical record contained no evidence that the nursing staff developed a plan of care to address removing Resident 23's brace every two hours to check her skin integrity under the brace. The Treatment Administration Record (TAR) for Resident 23 dated May 2011, revealed that the nursing staff added the brace which was ordered by the physician to the TAR, but failed to indicate any schedule for removing the brace from Resident 23's foot and ankle every two hours to check her skin. The facility was unable to provide electronic documentation that the nursing staff followed the brace and splint protocol. Resident 23's clinical record contained a physician's orders [REDACTED]. On June 10, 2011, at 10:45 AM, the surveyor observed Resident 23's left lower extremity with Employee 1, Registered Nurse. The Surveyor observed a scabbed (encrusted) area on the outer aspect of Resident 23's left foot. The surveyor also observed that Resident 23 was not wearing a heel protector on her right foot, and the left foot heel protector was applied above her ankle, and not covering her heel. Interview with the Nursing Home Administrator on June 10, 2011, at 11:30 AM, confirmed that the facility failed to follow the brace and splint protocol to prevent skin breakdown for Resident 23 and failed to apply her heel protectors in a manner to prevent further skin breakdown. 483.25(c) Treatment/services to Prevent/heal Pressure Sores. Previously cited 4/17/09 28 Pa. Code 211.10(d) Resident care policies. Previously cited 4/17/09, 5/7/10 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/17/09, 5/7/10