Every finding on record at Camp Hill Skilled Nursing and Rehabilitation CTR

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident right to receive treatment and care in accordance with professional standards of practice and the residents' choices for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled Code Status Orders last revised [DATE], read, in part, Code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Patient identification mechanisms and information about each patient's code status will be easily accessible to the clinical staff for all patients. All patients require a code status order as soon as possible upon admission/re-admission, a change in patient preference, or a significant change in patient condition. Purpose: To ensure that the patient's desired resuscitation wishes are documented in the medical record. Upon admission/re-admission, a code status order is required as soon as possible as part of the patient's admission order set. Orders for code status include Full Code or Do Not Resuscitate (DNR). Staff should verify the patient's wishes with regard to code status (Full Code vs. DNR) upon admission. If the patient wishes are different from the admission orders, immediately document the patient's wishes in the medical record, notify the physician, and obtain the correct order. Review of Resident 1's clinical record revealed diagnoses that included orthostatic hypotension (low blood pressure that occurs when standing or after sitting or lying down) and unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets). Review of Resident 1's clinical record revealed he was admitted to the facility from the hospital on [DATE], around 5:30 PM, and was sent back to the hospital on [DATE], around midnight. Review of Resident 1's clinical record revealed a RN (Registered Nurse) Assessment late entry note written by Employee 1 (RN) on [DATE], at 5:00 AM, detailing the Resident's change in condition that read, in part, Received order to transfer resident out to the hospital. 911 was immediately called at 11:55 PM. This writer made a copy of resident discharge summary from the hospital for EMS (Emergency Medical Services) and noted that he had a blank POLST (Physician Orders for Life Sustaining Treatment- is a medical order that allows seriously ill or frail individuals to specify the types of medical treatment they want during emergencies), in his chart as well as a copy of a POLST that was filled out as a full code. Upon reviewing his discharge summary, it was noted that resident was to be comfort care and Hospice care but no POLST was filled out and he had no hospice book at the desk. EMS asked if we knew if resident would want intravenous fluids and staff was unsure at the time. Spoke with EMS about resident not having a POLST filled out despite having a DNR bracelet and he was going to be acknowledged as a full code according to EMS staff. Resident transported back to hospital. Responsible Party (RP) called into facility at 1:05 AM and explained situation to RP. RP stated 'I was told by the hospital social worker that everything was already set up there and the hospital called asking me what I wanted to do.' Explained to RP that more than likely everything was done but this writer did not really have [anything] to go back on hence why he was sent back out. RP was unsure about what to do with patient because he is supposed to be a DNR and RP was under the impression that he was a DNR while here but informed him that patient was a full code. Notified RP to let the hospital know that he just wants patient to be DNR, comfort measures, Hospice, and no IV fluids (intervention) for his low blood pressure. RP called back again at 1:14 AM, and reported that patient will be coming back to facility. Review of Resident 1's POLST form scanned into his electronic health record and in his physical paper record revealed under the CPR section it was marked DNR (Do Not Resuscitate- a medical order indicating that a person does not want CPR or other life-saving measures if their heart or breathing stops) and dated [DATE]. Review of Resident 1's clinical record failed to reveal any POLST form noting that he was a full code. Review of Resident 1's physician orders revealed an order for DNR with a start date of [DATE], and discontinued date of [DATE]; and an order for Full Code from [DATE], with a discontinued date of [DATE]. Further review of Resident 1's physician orders failed to reveal an order for a code status at the time of his hospital transfer on [DATE]. Review of Resident 1's clinical record revealed an After Visit Summary from his hospitalization from [DATE], to [DATE], that read, in part, We discussed this case with your family, and the decision was made to pursue comfort measures and hospice care. You will be discharged on hospice care. Review of Resident 1's clinical record revealed a document titled New Admission that was not dated, that noted his code status was DNR. It also noted he was on comfort care and long-term care with hospice. Review of document titled admission Medication Reconciliation Checklist dated [DATE], revealed it was blank on the first page, including the section under Discharge Documentation Review noting Code status verified and entered. The second page was checked off under Second Nurse Verification by Employee 1 on [DATE], at 1:00 AM, and was checked as completed for any discrepancies clarified with provider and was left blank if there was a discrepancy found. Review of hospital after visit summary from hospitalization on [DATE], read, in part, This patient was seen here in the ED but upon further investigation he is currently on comfort care and DNR/DNI (Do Not Intubate). I confirmed this information with the patient's son who requested the patient be transferred back to this nursing facility. He confirmed that the plan is to have this patient on comfort care. During an interview with the Director of Nursing (DON) on [DATE], at 11:28 AM, she acknowledged that there was a discrepancy between the hospital discharge summary, and the nurse's note of his code status. She revealed she was unable to locate the POLST for a full code that was referenced and she wasn't sure if the nurse had documented that in error, and education had been given to staff in response to this incident related to timely documentation of physician orders and recommendations from the hospital. She further revealed that the new admission document was likely from his hospital return on [DATE], as it noted the new order from that hospitalization for morphine, and that his last bowel movement was on [DATE]. During a follow up interview with the DON on [DATE], at 11:47 AM, she revealed the facility has a process improvement plan in place to ensure the hospital admission process is completed properly, timely, and orderly. 28 Pa. Code 201.29 (a) Resident Rights28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide residents food that accommodates resident allergies, intolerances, and preferences for two of nine residents reviewed (Residents 4 and 8).Findings include: Review of Resident 4's clinical record documented diagnoses that included depression (feelings of severe despondency and dejection), osteoarthritis (cartilage inside a joint wear down, leading to joint pain), and pain in unspecified hand. Interview with Resident 4 on August 5, 2026, at 12:15 PM, she stated that she received fish and she was allergic to fish. At that time, observation of her tray revealed she was served fish, mashed potato and regular portion (1/2 cup) of California Blend vegetables. Review of Resident 4's physician orders included Regular/Liberalized diet Dysphagia Advanced texture, Standard Thin Liquids consistency, Regular pleasure foods. Further clinical review revealed no documentation of a fish allergy, required set-up assistance with meals, and to honor food preferences within the meal plan. Review of her tray ticket documented ground beef goulash 7 oz, ground vegetable blend 3/4 cup, garlic mashed potato with gravy 1/2 cup, gelatin 4 oz, applesauce 1/2 cup, notes included gravy in a bowl not on top, and no fish. Interview with Employee 1 (Nursing Assistant), revealed she called Dietary and asked for them to send the goulash for Resident 4. At 12:31 PM, Resident 4 was offered the goulash and she refused it. At that time, the Resident stated she didn't want the goulash and wasn't going to eat. Based on email communication with the Nursing Home Administrator (NHA) August 6, 2026, at 3:58 PM, the facility does have a list of menu items that are always available, and that the list is provided to each resident. If a resident completes a select menu, they can write always available items on the menu prior to submitting the menu to the kitchen. The NHA was made aware of the concern that Resident 4's tray ticket documented No Fish and she was served fish. Upon following up with Dietary, NHA revealed that Resident 4 was served fish in error. Review of Resident 8's clinical record documented diagnoses that included heart failure, encephalopathy, weakness, ileostomy, and liver/bile duct, Colon and bladder cancer. Review of Resident 8's physician orders included 2 gm sodium, regular textures, thin liquids; palliative care referral for metastatic sigmoid adenocarcinoma. Further review of Resident 8's clinical record documented Resident was at nutritional risk for malnutrition; honor food preferences within meal plan. Interview with Resident 8 on August 5, 2026, at 2:50 PM, revealed she completes a select menu, doesn't receive the items requested and, when she asks staff for the items, she is often told they don't have it. At times she knows it is a lie because her roommate was served the item she is requesting. It was also revealed she requested the fish on August 5, 2026, and received the goulash and, when asked for fish, was told they didn't have fish. Review of Resident 8's selected menu, provided by dietary, revealed the goulash was crossed out (does not wish to be served - provide the alternate fish). Interview with the NHA on August 5, 2026, at 3:30 PM, it was revealed that Resident 8 crossed out the goulash on her select menu and she should've received the fish. 28 Pa code 211.6(a) - Dietary Services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include: Review of facility policy, titled Food Storage: Cold Foods last reviewed February 5, 2026, read, in part, All Time/Temperature Control for Safety foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Freezer temperatures will be maintained at a temperature of 0 degrees F (Fahrenheit- unit of measure) or below. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation in the dry storage area on February 24, 2026, at 9:28 AM, revealed one open container of ziti pasta not dated with an open date; one open package of fettucine pasta not dated with an open date; one open container of croutons not dated with an open date; three bags of dinner rolls not dated; one package of hot dog buns dated use by February 21, 2026; and nine packages of hot dog buns dated use by February 12, 2026. Further observation of two of the hot dog bun packages dated use by February 12, 2026, had spots consistent with mold on them. Observation of Reach in Refrigerator 1 on February 24, 2026, at 9:34 AM, revealed the bottom and the sides of the refrigerator were heavily soiled with debris and spill marks. Observation of Reach in Refrigerator 2 on February 24, 2026, at 9:35 AM, revealed one bin of turkey sausage dated use by February 23, 2026; and one bin of carrots not dated. Observation of Reach in Refrigerator 3 on February 24, 2026, at 9:37 AM, revealed one open container of strawberry lemonade without an open date. Further observation of Reach in Refrigerator 3 revealed the bottom and the sides of the refrigerator were heavily soiled with debris and spill marks. Interview with Employee 4 (Dietary Manager) on February 24, 2026, at 9:37 AM, he revealed the strawberry lemonade should be discarded; all open food and beverage containers should be labeled with an open date; and the refrigerators and freezers should be kept clean and are on a weekly cleaning schedule. Observation of Reach in Freezer 1 on February 24, 2026, at 9:38 AM, revealed three bags of mixed vegetables not dated. Further observation of the Reach in Freezer 1 on February 24, 2026, at 9:39 AM, revealed the temperature gauge read 17 degrees F. Interview with Employee 4 on February 24, 2026, at 9:40 AM, revealed Reach in Freezer 1 was left open by an employee for about 30 minutes that morning, so it needed time to return to the appropriate temperature. Observation of Reach in Freezer 3 on February 24, 2026, at 9:42 AM, revealed the bottom of the sides of the freezer was heavily soiled with debris. Observation in the main kitchen on February 24, 2026, at 9:43 AM, revealed four bins of assorted cereal dated use by January 15, 2026. Further observation in the main kitchen on February 24, 2026, at 9:44 AM, revealed one bin of thickener labeled November 6, 2025, and was caked with debris. The inside of the bin had a scoop stored inside and had black specks throughout the white thickener powder. Observation of a bin of sugar in the main kitchen on February 24, 2026, at 9:46 AM, revealed it was dated use by January 10, 2026, and there was a scoop stored inside. Interview with Employee 4 on February 24, 2026, at 9:48 AM, revealed scoops should not be stored inside the thickener and sugar bins, and they should be replenished and cleaned at least every two months. Review of the 2025 Dish Machine Temperature Logs revealed logs were unable to be located for the months of October, November and December. Interview with Employee 4 on February 24, 2026, at 10:03 AM, he revealed his expectation that food is stored and kitchen equipment is utilized in accordance with professional standards for food service safety. Return visit to the kitchen on February 25, 2026, at 12:54 PM, revealed the Reach-in Refrigerators 1 and 3 had appeared to be cleaned, but remained with debris and spill marks. Interview with Employee 4 on February 25, 2026, at 12:55 PM, revealed staff attempted to clean the reach in refrigerators, but they are so heavily soiled they will have to be deep cleaned and scrubbed further. During an interview with the Nursing Home Administrator (NHA) on February 25, 2026, at 2:06 PM, the surveyor revealed the concern with food storage in the kitchen, as well as the dirty kitchen equipment and lack of dish machine temperature logs for review from October 2025 to December 2025. The NHA revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of three nursing units observed. Findings include: Review of facility policy, titled Safe and Homelike Environment last reviewed January 5, 2026, read, in part, The resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. The center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observations in Resident 22's room on February 24, 2026, at 10:30 AM and at 2:12 PM, revealed the wall was damaged in a corner of the room, the baseboard was coming away from the wall, four of the ceiling tiles in her room had brown stains on them, and there were holes in the wall above her bed. Observation in Resident 22's room on February 25, 2026, at 9:51 AM, revealed the wall was damaged in a corner of the room, the baseboard was coming away from the wall, four of the ceiling tiles in her room had brown stains on them, and there were holes in the wall above her bed, consistent as the day before. Observations in Resident 26's room on February 24, 2026, at 10:30 AM and at 2:11 PM, revealed her tray table was dirty with a spilled liquid, and the floor around her bed was dirty. Observation in Resident 26's room on February 25, 2026, at 9:50 AM, revealed her tray table was dirty with a spilled liquid, and the floor around her bed was dirty, consistent as the day before. Observations in Resident 30's room on February 24, 2026, at 10:25 AM and at 2:11 PM, revealed the table on the side of her bed was dirty with several rings from beverage cups, and the floor underneath the table was dirty. Observation in Resident 30's room on February 25, 2026, at 9:49 AM, revealed the table on the side of her bed was dirty with several rings from beverage cups, and the floor underneath the table was dirty, consistent as the day before. Observations in Resident 84's room on February 24, 2026, at 12:27 PM and at 2:13 PM, revealed the baseboard was coming away from the wall and the wall was damaged. Observation in Resident 84's room on February 25, 2026, at 9:52 AM, revealed the baseboard was coming away from the wall and the wall was damaged, consistent as the day before. During an interview with the Nursing Home Administrator (NHA) on February 25, 2026, at 2:04 PM, the surveyor communicated the environmental concerns in Resident 22's, 26's, 30's, and 84's rooms, the NHA revealed the concerns would be addressed immediately, and he would expect the facility to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and home-like environment.28 Pa. Code 201.18(e)(2.1) Management

Based on facility policy review, review of facility diet extension sheets, review of nutrition facts label, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician for six of 36 residents reviewed on a consistent carbohydrate diet (Residents 5, 8, 15, 52, 68, and 106). Findings include: Review of facility policy, titled Consistency Alterations and Therapeutic Menus last reviewed January 5, 2026, read, in part, The menu is written for a regular/liberalized diet and is extended for a number of therapeutic diets. Purpose: to provide diets as ordered by the physician/advance practice provider (APP). The menu is extended for the following therapeutic diets [including] Consistent Carbohydrate. Review of facility diet extension sheet for the lunch meal on February 25, 2026, revealed the regular/liberalized diet should be served a slice of angel food cake, and the consistent carbohydrate diet should be provided a slice of diet angel food cake. Observations during tray line meal service on February 25, 2026, between 12:07 PM and 12:41 PM, revealed Residents 5, 8, 15, 52, 68, and 106 were served a piece of angel food cake on their trays. Review of physician orders for Resident 5, 8, 15, 52, 68, and 106 revealed they were ordered a consistent carbohydrate diet for diabetes. Review of physician orders for Resident 4, 6, 7, 9, 10, 16, 20, 24, 31, 35, 49, 50, 59, 64, 67, 69, 75, 77, 78, 85, 87, 88, 89, 96, 99, 104, 109, 110, 123, 124, and 126, revealed they were also ordered a consistent carbohydrate diet for diabetes. During an interview with Employee 4 (Dietary Manager) on February 25, 2026, at 12:46 PM, he revealed the angel food cake served at lunch today was the same angel food cake served across all diet orders. Review of the nutrition facts and ingredients label for Angel Food [NAME] Cake served at the lunch meal on February 25, 2026, revealed the cake contained 28 grams of total carbohydrates and 20 grams of sugar. Further review of the ingredients revealed the number one ingredient of the cake was sugar, and there were no sugar substitutes present in the ingredients. Interview with the Nursing Home Administrator on February 25, 2026, at 2:06 PM, revealed he would expect therapeutic diets to be provided as ordered and extension sheets to be followed for therapeutic diet alterations. 28 Pa Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure pain management is provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of 24 residents reviewed (Resident 86).Findings include: Review of the facility policy, titled Pain Management , last revised on March 24, 2025, revealed, staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. Review of Resident 86's clinical record revealed diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone) and dementia (a decline in the mental abilities you need for daily living). Review of Resident 86's care plan revealed a focus area that the Resident was at risk for alterations in comfort related to impaired mobility, diagnosis of multiple fractures on left side ribs, polyneuropathy, and pain, created on January 7, 2026, and revised on January 16, 2026. Further review of the care plan revealed an intervention to medicate Resident as ordered for pain and monitor for effectiveness and monitor for side effects, created and initiated on January 13, 2026. Review of Resident 86's clinical record revealed a physiatry progress note written on January 8, 2026, at 11:37 PM, that read, in part, Patient's pain is not currently well controlled. She is currently on Tylenol routine, oxycodone 2.5 milligram (mg) every four hours as needed. Will order her lidocaine patch to ribs be routine. Review of Resident 86's physician's orders revealed an order for: lidocaine external patch 4%, apply to area needed topically one time a day for pain, effective January 7, 2026, and discontinued on January 13, 2026. The order failed to specify where the patch was to be placed. Further review of Resident 86's physician's orders revealed an active order for: lidocaine external patch 4%, apply to area needed topically one time a day for pain and remove per schedule, effective January 14, 2026. The physician's order failed to specify where the patch was to be placed. Review of Resident 86's February 2026 TAR (Treatment administration record) revealed that on February 13, 14, 15, 16, 17, 19, 20, 21, and 24, 2026, Resident 86 was not administered the lidocaine patch as ordered. Review of Resident 86's clinical record revealed a nursing progress note on February 16, 2026, at 5:17 AM, that the lidocaine patch was not administered, with note text that read, in part, Not available, where is this supposed to go? Resident will not be able to say. Review of Resident 86's clinical record revealed a nursing progress note on February 17, 2026, at 5:08 AM, that the lidocaine patch was not available, no details on where this goes, and the Resident was unable to say where it goes. Review of Resident 86's clinical record revealed a nursing progress note on February 19, 2026, at 5:20 AM, that their lidocaine patch was not administered, there was no indication of where to apply, and the Resident was unable to assist. Review of Resident 86's clinical record revealed a nursing progress note on February 20, 2026, at 5:12 AM, that the lidocaine patch was not administered, and requested clarification of placement as the Resident was not able to assist in saying where to put it. Review of Resident 86's clinical record revealed a nursing progress note on February 21, 2026, at 5:08 AM, that the lidocaine patch was not administered, and the order needs clarification as there is no site noted and the Resident was unable to assist in where to put it. Review of Resident 86's clinical record revealed a nursing progress note on February 24, 2026, at 5:13 AM, that the lidocaine patch was not administered, there is no notation on where to put patch and the Resident was unable to assist in placement. Clarification has been asked for but has not yet been answered by provider. Review of Resident 86's January 2026 and February 2026 TARs revealed that when the lidocaine patch was administered, it was documented as being administered on the Resident's right hip, right arm, right thigh, left hip, lower back, or right deltoid. There was one day, February 5, 2026, where the patch was documented as being administered on their abdomen, lower left quadrant. Besides that, there has been no documentation of the Resident's lidocaine patch being administered to their ribs. Interview conducted with the Director of Nursing on February 26, 2026, at 10:03 AM, revealed that she would expect placement of Resident 86's lidocaine patch to have been added to the order and for it to have been administered as ordered by the physician. 28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 7).Findings Include: Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, effective May 1, 2024, revealed, Process: 6. The Center will identify triggers which may re-traumatize patients with a history of trauma. Trigger specific interventions will identify ways to decrease the patient's exposure to triggers which re-traumatize the patient, as well as identify ways to mitigate or decrease the effect of the trigger on the patient and will be added to the patient's care plan. Review of Resident 7's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and major depressive disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). Review of Resident 7's clinical record revealed the Resident was seen by a psychiatry on December 31, 2025, and January 20, 2026, with documentation of the visit to include the Resident had trauma history with being abused as a child by stepfathers and prefers not to have male caregivers. Review of Resident 7's care plan on February 24 and 25, 2026, revealed a care plan for Resident 7 being at risk for distressed/fluctuating mood symptoms related to anxiety and PTSD, initiated and created on December 1, 2025. Further review of Resident 7's care plan failed to reveal an intervention that the Resident prefers not to have male caregivers, or any triggers identified. Review of Resident 7's clinical record revealed the Resident had a trauma assessment completed on February 25, 2026, at 12:52 PM, and scored a 4, which indicated a positive screen for trauma. Interview conducted with the Nursing Home Administrator on February 26, 2026, at 10:04 AM, revealed he would have expected Resident 7's trigger of male caregivers to have been added to her care plan prior to this date and have been in place. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on facility policy, staff interview, and clinical record review, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for one of five residents reviewed for psychotropic medication use (Resident 4). Findings included: Review of facility provided policy, titled NSG206 Behaviors; Management of Symptoms, revised September 25, 2025, revealed, When medication is ordered for behavioral symptoms: Obtain consent. Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 4's physician orders revealed an order for Zoloft (medication used to treat depression) 25 mg, given by mouth at bedtime for depression, starting on January 29, 2026. Further review revealed an order for Olanzapine (antipsychotic medication) 5 mg at bedtime for psychotic behaviors, starting on December 21, 2025. Review of Resident 9's Care plan revealed a focus of: Resident 4 is at risk for complications related to the use of psychotropic drugs, created on December 22, 2025. Review of Resident 9's medical record failed to reveal an explanation for the risks and benefits of psychotropic medications and consent for use of those medications by Resident 4 or their Representative. Interview with the Director of Nursing on February 25, 2026, at 1:45 PM, revealed that Resident 4 did not have the appropriate notifications made prior to starting psychotropic medications. 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were responded to by the attending physician or prescriber for one of five residents reviewed (Resident 4). Findings include: Review of facility policy, titled Medication Regimen Review and Reporting, revised January 2024, revealed, For recommendations that do not require physician intervention, the director of nursing or licensed designee will address the recommendations. Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 's medical record revealed a recommendation made on September 9, 2025, by the consultant pharmacist to add an parameters for Resident 4's PRN (as needed) pain medication. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity. Review of Resident 's medical record revealed a recommendation made on December 29, 2025, by the consultant pharmacist, to add an appropriate dose for Resident 4's pain medication. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity. Interview with the Director of Nursing on February 26, 2026, at 10:45 AM, revealed that they would expect the regulation to be followed and that the physician would review the irregularities, document what, if any, action has been taken to address it, and document his or her rationale in the resident's medical record. 28 Pa. Code 211.10(c) Resident care policies.

Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one of 26 residents reviewed (Resident 97) for respiratory care. Findings include: Review of facility provided policy, titled Oxygen: Concentrator, revised August 7, 2023, revealed when implementing supplemental oxygen for a resident, step 1. Verify order. Review of Resident 97's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive, incurable, but treatable lung disease) and obstructive sleep apnea (serious, common sleep disorder where throat muscles relax excessively, causing repeated airway collapse and breathing pauses [apnea] during sleep). Observation of Resident 97 on February 24, 2026, at 10:24 AM, revealed Resident 97 lying in bed. Resident 97 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 2 liters per minute. Review of Resident 97's care plan revealed a care plan of: Resident exhibits or is at risk for respiratory complications related to recent hospitalization, COPD, created on October 23, 2025. Review of current physician orders for Resident 97 failed to reveal a physician's order for supplemental oxygen. Interview with the Director of Nursing on February 26, 2026, at 10:15 AM, revealed that Resident 97 had an order for supplemental oxygen previously, but the order had not been renewed. 28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice for one of the 24 residents reviewed (Resident 5).Findings Include: Review of the facility's policy, titled Person-Centered Care Plan, recently reviewed January 5, 2026, defined professional standards of Quality as care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Review of Resident 5's clinical record revealed diagnoses that included cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged), chronic kidney disease (a long-term, progressive condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), and dementia (a loss of thinking, remembering, and reasoning skills). Review of Resident 5's census information revealed multiple hospital transfers and included a hospital transfer date of October 26, 2025, with a return and readmission to the facility on November 2, 2025. Review of the facility's document titled Consultant Pharmacist's Progress Note, dated November 4, 2025, revealed the following documented as Transcription Errors: Hospital d/c [discharge order] Lactulose 10 gm/15 m/-Give 30 ml TID [three times per day]. Current order: Lactulose 10 gm/15ml-Give 30 ml QD [once per day]. Upon review by the Certified Registered Nurse Practitioner (CRNP) (Employee 2), it was revealed that an agreement to change the lactulose order to the recommended dosage made on the hospital discharge summary. Review of the pharmacist's progress notes also revealed Hospital d/c order-Tamsulosin 0.4 QD. Current order - Tamsulosin 0.4 mg-Give 2 capsules (0.8mg). Upon review by Employee 2, an agreement was documented to change to 0.4 mg 1 cap at HS [hour of sleep- bedtime]. Review of the pharmacist's progress notes revealed Hospital d/c order-Bumetanide 1 mg BID [twice per day]. Current order- Bumetanide 0.5 mg BID. Upon review by Employee 2, an agreement was documented to change the medication order to Bumetanide 1 mg BID. Continued review of Resident 5's monthly consultant pharmacy recommendation for the Resident's physician to address, dated November 20, 2025, read Per DC [discharge summary] resident was ordered levothyroxine 37.5 mg po [by mouth] ONCE DAILY. On 11/3/2025, it was ordered twice daily; this med [medication] typically dosed once daily. Upon review of the pharmacy recommendation, Employee 2 agreed with the recommendation and documented Please change to 37.5 mcg ONCE daily. An interview with the Director of Nursing on February 26, 2026, at 10:15 AM, revealed that the Registered Nurse (Employee 1) did not have possession of Resident 5's hospital discharge record and used the prior medication list to review with the physician at Resident 5's readmission to the facility. The interview revealed that Employee 1 should have used the hospital discharge medication order recommendations to review with the physician and add to Resident 5's clinical record instead of Resident 5's medications listed before the hospitalization. 28 PA. Code 211.12 (d) (1) (2) (5) Nursing services

Based on clinical record review, document review, and staff interview, it was determined that the facility failed to ensure residents are informed of the items and services that are included in nursing facility services for which the resident may not be charged and those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for three of three residents no longer eligible for Medicare A benefits coverage reviewed (Residents 120, 121, and 122).Findings Include: Review of Resident 120's clinical record revealed an admission date to the facility on November 25, 2025. Review of Resident 120's census information revealed the most recent date of Medicare A coverage that began on December 22, 2025, and ended on December 23, 2025. Review of Resident 120's Skilled Nursing Facility Beneficiary Notification Review form revealed the Resident had not been provided with the required Skilled Nursing Facility-Advance Beneficiary Notice of Non-Coverage form (SNF-ABN) to be informed of the cost of the items and services no longer covered under Medicare A and the cost of those items and services. Review of Resident 121's clinical record revealed an admission date to the facility on December 17, 2025. Review of Resident 121's census information revealed the most recent date of Medicare A coverage that began on January 1, 2026, and ended on January 16, 2026, when the Resident was discharged home from the facility. Review of Resident 121's Skilled Nursing Facility Beneficiary Notification Review form revealed the Resident had not been provided with the required Notice of Medicare Non- Coverage (NOMNC) form to indicate that her stay was no longer covered under Medicare A. Review of Resident 122's clinical record revealed an admission date to the facility on August 8, 2025. Review of Resident 122's census information revealed the most recent date of Medicare A coverage that began on September 21, 2025, and ended on October 26, 2025. Review of Resident 122's Skilled Nursing Facility Beneficiary Notification Review form revealed the Resident had not been provided with the required SNF-ABN form to be informed of the cost of the items and services no longer covered under Medicare A and the cost of those items and services. An interview with the Nursing Home Administrator on February 24, 2026, at 12:15 PM, confirmed the facility had not provided those residents with the required notices. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one of two residents reviewed (Resident 8).Findings include: Review of Resident 8's clinical record revealed diagnoses that included polyneuropathy (a nerve disease caused by damage to many nerves) and hypertension (high blood pressure). Observation conducted of Resident 8 on February 24, 2026, at 10:13 AM, revealed the Resident was lying in bed, not wearing a float heel, and did not have any pillows placed under their foot. Interview conducted with Resident 8 on February 25, 2026, at 11:58 AM, revealed that he hardly ever wears a right heel boot as staff do not place it on him. Resident 8 revealed his heel boot was in his closet. Observation conducted of Resident 8 on February 25, 2026, at 11:59 AM, revealed the Resident lying in bed, not wearing a float heel, and did not have any pillows placed under their foot. Observation conducted of Resident 8 on February 25, 2026, at 12:36 PM, revealed the Resident lying in bed, without a float heel on. Review of Resident 8's care plan revealed a focus area that the Resident is at risk for skin breakdown related to pressure ulcer to right heel, revised on January 23, 2026; with an intervention to wear a prevalon boot to right foot when in bed. Review of Resident 8's clinical record revealed the Resident had a wound assessment completed on January 15, 2026, for a pressure ulcer on their right heel, with a nutrition recommendation for a dietitian consultation, as well as a recommendation to place heel-float boots to bilateral feet while in bed to offload the heels. The facility was unable to provide documentation that a dietary consultation has been made or conducted per the wound assessment recommendation above for Resident 8. Review of Resident 8's clinical record revealed their most recent dietary consult was conducted on September 29, 2025. Review of Resident 8's clinical record revealed the Resident had a wound assessment completed on January 22, 2026, with the following treatment recommendations: primary dressing: 1. Santyl ointment; secondary dressing: 1. Vashe moistened gauze 2. Foam; this treatment will be done daily and as needed until discontinued. Review of Resident 8's January 2026 TAR (Treatment administration record) revealed an order for: Santyl External Ointment 250 unit/gram (Collagenase); apply to right heel topically every day shift for pressure ulcer, with a start date of January 23, 2026, and a discontinue date of January 31, 2026. The order failed to include the secondary dressing in the recommendation from the wound assessment above on January 22, 2026. Review of Resident 8's February 2026 TAR revealed an order for: Right heel boots on all the time except for care every shift for pressure ulcer prevention, with a start date of October 23, 2025. Further review of the TAR revealed that on February 24 and 25, 2026, during every shift, it was documented that Resident 8 was wearing a right heel boot. During an interview with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 10:05 AM, revealed they would expect Resident 8 to be wearing their heel boot as ordered and documented, would expect wound assessment recommendations to be completed, and for wound orders to be put in correctly. 28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, facility policy review, medical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents reviewed (Resident 8).Findings include:Review of facility policy, NSG213 Enteral Management, revised July 22, 2025, failed to reveal any expectation that tube feeding solution would be labeled with the name of the solution and date/time that the tube feeding was initiated.Review of Resident 8's clinical record revealed diagnoses that included Acute kidney failure (a sudden and often temporary loss of kidney function) and diabetes (a disease that affects how the body manages blood sugar).Observation of Resident on October 6, 2025, at 1:45 PM, revealed a bottle of beige liquid hanging at Resident 8's bedside in an open tube feeding set-up (bottle and tubing used to administer tube feedings). The bottle was not labeled with what tube feeding was contained inside, the initials of the individual who hung it, or the date and time that it was hung for use.Review of current physician orders for Resident 8 revealed an order for Glucerna 1.5 (kind of tube feeding solution) to be administered at 66 milliliters per hour for 22 hours daily, starting September 20, 2025.Review of Resident 8's plan of care revealed a focus area of Resident has an enteral feeding tube to meet nutritional needs, with a revision date of September 18, 2025Interview with Employee 1 (Licensed Practical Nurse) on October 6, 2025, at 1:45 PM, revealed that she did not hang the tube feeding solution at Resident 8's bedside and that it was already there when she arrived at 6:30 AM that morning. She also stated that she did not know when it was put there and that, although she assumed that it was Glucerna 1.5 as per physician order, she had no way of knowing.Interview with the Nursing Home Administrator on October 6, 2025, at 2:15 PM, revealed that he would expect the tube feeding solution to be labeled with the contents and time/date that it was hung. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of eight residents on transmission-based precautions reviewed (Residents 7).Findings Include:Review of facility policy, IC308 Enhanced Barrier Precautions (EBP), revised December 6, 2024, revealed that residents with a wound or indwelling medical device will be placed on EBP if they do not meet criteria to require contact precautions.Review of Resident 7's clinical record revealed diagnoses that included pressure ulcer of left heel (an injury to the skin and/or underlying tissue caused by prolonged pressure) and chronic kidney disease (gradual loss of kidney function).Review of Resident 7's care plan revealed a current care plan for skin breakdown related to impaired mobility, Pressure ulcer left heel stage 2, with a revision date of August 20, 2025.Observation of Resident 7's room on October 6, 2025, at 12:30 PM, revealed no sign on Resident 7's door indicating that the Resident was on EBP. Further observation of Resident 7 at that time revealed her lying in bed while Employee 2 (Licensed Practical Nurse) completed a dressing change on her left heel. Employee 2 only wore gloves for personal protective equipment and no gown, as is required for high contact resident activities such as a dressing change.Interview with Employee 2 October 6, 2025, at 12:30 PM, revealed that Resident 7 was not on EBP at that time.Review of Resident 7's current physician orders failed to reveal a physician's order for EBP.Interview with the Director of Nursing on October 6, 2025, at 2;15 PM, revealed that Resident 7 should be on EBP and she will ensure EBP will be initiated moving forward.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, select facility document review, facility training records, and staff interview, it was determined that the facility failed to ensure that residents received adequate assistance to prevent falls, which resulted in harm as evidenced by a fracture of the right hip for one of three residents reviewed for falls (Resident 1).Review of facility policy titled, NSG200 Activities of Daily Living (ADLs), last revised May 1, 2023, revealed Activities of Daily Living (ADLs) were defined as, Hygiene - bathing, dressing, grooming, and oral care;.Elimination - toileting. Review of the policy purpose revealed it stated, To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences.Review of Resident 1's clinical record revealed diagnoses that included history of cerebral infarction (also known as stroke or cerebral vascular accident - sudden loss of blood flow or bleeding into the brain that causes brain cell death) above the knee amputation of the right leg and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).Review of Resident 1's comprehensive plan of care revealed a care plan with a focus of, ADL self care deficit as evidenced by generalized weakness related to physical limitations, history of [cerebral vascular accident], which was last revised August 23, 2024. Review of Resident 1's ADL care plan revealed the intervention of, ADL Assist: Assist of two [staff members] with ADL's, which was last revised on April 17, 2024.Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, Dressing/Grooming/Bathing, which stated, ADL Assist of two with ADL's.Review of facility incident report dated October 16, 2025, revealed Resident 1 sustained a witnessed fall from bed at 11:45 AM. Review of the Incident Description, revealed it stated, During brief change [Resident 1] was holding on the [sic] arm of the chair next to bed and the chair moved and [Resident 1] kept rolling off the bed and was lowered to the floor by CNA [Employee 1 - Nurse Aide]. Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 had pain in the right hip, left knee and ankle, and that an x-ray of the area had been ordered.Review of x-ray results dated October 16, 2025, revealed Resident 1 suffered a right-sided acute intertrochanteric fracture (hip fracture). Resident 1 was subsequently sent to the hospital emergency room for evaluation and treatment. Resident 1 was deemed not appropriate for surgical intervention due to multiple health factors.Review of a witness statement by Employee 1, dated October 16, 2025, revealed Employee 1 stated, I did not know that [Resident 1] needed 2 people until after the incident. I did check her Kardex and did not see where it said 2 assist for toileting. I was providing incontinence care, I was not aware that incontinence care is considered an ADL.Review of the Care Plan and Kardex for Resident 1 revealed that the only assist level noted during the time of the fall was for a two person assist.Employee 1 failed to ensure Resident 1 was free from accident hazards by performing incontinence care independently, instead of with a second employee per Resident 1's plan of care, which resulted in Resident 1 falling from her bed and sustaining a right hip fracture.During an interview with the Nursing Home Administrator (NHA) on October 23, 2025, at approximately 11:45 AM, he revealed it was his expectation that facility nursing staff should know that incontinence care is considered an activity of daily living. Further, the NHA revealed that he expected facility staff to follow residents' plans of care.201.4(a) Responsibility of licensee201.18(b)(1)(e)(1) Management211.10(c)(d) Resident care policies211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined the facility failed to ensure each resident was free from neglect, which resulted in actual harm as evidenced by fracture of the right hip for one of three residents reviewed (Resident 1).Review of facility policy, titled OPS 300 Abuse Prohibition with a last revision date of October 24, 2022, revealed Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of Resident 1's clinical record revealed diagnoses that included history of cerebral infarction (also known as stroke or cerebral vascular accident - sudden loss of blood flow or bleeding into the brain that causes brain cell death), right- above the knee amputation and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).Review of Resident 1's comprehensive plan of care revealed a care plan with a focus of, ADL [Activities of Daily Living] self care deficit as evidenced by generalized weakness related to physical limitations, history of [cerebral vascular accident], which was last revised August 23, 2024. Review of Resident 1's ADL care plan revealed the intervention of, ADL Assist: Assist of two [staff members] with ADL's, which was last revised on April 17, 2024.Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, Dressing/Grooming/Bathing, which stated, ADL Assist of two with ADL's.Review of facility incident report dated October 16, 2025, revealed Resident 1 sustained a witnessed fall from bed at 11:45 AM. Review of the Incident Description, revealed it stated, During brief change [Resident 1] was holding on the [sic] arm of the chair next to bed and the chair moved and [Resident 1] kept rolling off the bed and was lowered to the floor by CNA [Employee 1 - Nurse Aide]. Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 had pain in the right hip, left knee and ankle, and that an x-ray of the area had been ordered.Review of X-ray results dated October 16, 2025, revealed Resident 1 suffered a right-sided acute intertrochanteric fracture (hip fracture). Resident 1 was subsequently sent to the hospital emergency room for evaluation and treatment. Resident 1 was considered for surgery; however, found not to be a candidate for surgery due to health conditions.Review of a witness statement by Employee 1 dated October 16, 2025, revealed Employee 1 stated, I did not know that [Resident 1] needed 2 people until after the incident. I did check her Kardex and did not see where it said 2 assist for toileting. I was providing incontinence care, I was not aware that incontinence care is considered an ADL.Review of the Care Plan and Kardex for Resident 1 revealed that the only assist level noted during the time of the fall was for a two person assist. Review of Employee 1's facility education revealed that Employee 1 completed the following education modules: Bed safety on October 9, 2025. Abuse & Neglect OTS on September 5, 2025. 2025 Q3 Mandatory Safe Resident Handling Training - Clinical Employees, on July 3, 2025. Safe Resident Handling: Active Transfers and Mobility - Clinical Staff, on July 3, 2025. SQ LTC: Falls, Assessment and Prevention, on July 3, 2025. Patient Rights and abuse & Neglect Prevention, on June 20, 2025. SQ LTC: Abuse and Neglect, on April 6, 2025. SQ LTC: Patient or Resident Safety Basics, Patient-Facing, on April 6, 2025.Employee 1 failed to follow the plan of care for Resident 1 and proved incontinence care independently, instead of with a second employee, which resulted in Resident 1 falling from her bed and sustaining a right hip fracture.During staff interview with the Nursing Home Administrator (NHA) on October 23, 2025, at approximately 11:45 AM, he confirmed that Employee 1 neglected to follow the plan of care for Resident 1 by failing to provide ADL care with two staff, which resulted in Resident 1 falling from the bed and sustaining a fracture of the right hip, requiring a transfer to the hospital. During the staff interview, the NHA confirmed that Employee 1 was terminated from her position as a result of the facility investigation.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(e)(1) Management28 Pa. Code 201.29 (a) Resident rights28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three of five residents reviewed for limited range of motion (Residents 35, 40, and 50). Findings include: Review of facility policy, titled Restorative Nursing Guidelines, dated April 1, 2024, read, in part, Restorative nursing services (RNP) refer to interventions that promote the patient's ability to adapt & adjust to living as independently & safety as possible. It includes interventions that promote the resident's ability to attain & maintain their maximum functional potential. RNP's include, but are not limited to: Active Range of Motion (AROM) & Passive Range of Motion (PROM). Developing a RNP includes patient need identification, program design, documentation & monitoring outcomes. The program must include documentation of the number of minutes spent per restorative session. Document daily restorative nursing 'tasks' include interventions provided, time in minutes that restorative nursing care was provided, and patient tolerance of nursing interventions. Review of Resident 35's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side, aphasia (language disorder that affects a person's ability to communicate), and vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults). Review of Resident 35's current physician orders revealed an order for right palm guard on at all times except for hygiene. Check skin daily every shift, dated July 17, 2024. Observations of Resident 35 on January 13, 2025, at 11:47 AM and 12:14 PM; on January 14, 2024, at 9:24 AM and 1:31 PM; and January 15, at 9:44 AM, all revealed that Resident 35 did not have a palm guard in place in their right hand. Review of Resident 35's Treatment Administration Records from July 1, 2024, through December 31, 2024, revealed that Resident 35's palm guard was documented as being applied; however, review of Resident 35's January 2025 Treatment Administration Record failed to include the palm guard as an ordered treatment to be provided. Review of Resident 35's care plan revealed a focus for ADL [Activities of daily living or ADLs are routine tasks that each of us must perform every day to care for our bodies and ourselves independently] self-care deficit related to physical limitations with a revised date of November 7, 2024. Interventions included, but were not limited to, Passive Range of Motion to right upper extremity during ADLs dated August 13, 2024; and Restorative Dressing/Grooming: Resident will raise her arms, as tolerated, to assist with putting arms into clothing/gown, during AM and PM care moderate assist, with a revised date of March 20, 2024. Review of Resident 35's Restorative Nursing Program documentation from November 1, 2024, through January 15, 2025, revealed the following: Restorative Dressing/Grooming and Restorative Range of Motion were blank for day shift on November 7, 15, and 21, 2024; were blank for evening shift on November 19, 2024; were blank for day shift on December 4 and 31, 2024; were blank for evening shift on December 9 and 30, 2024; and were blank on day shift on January 9, 10, and 11, 2025; and were blank for evening shift on January 6 and 12, 2025. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 16, 2025, at 12:21 PM, the DON indicated that she had no additional information to provide regarding Resident 35's palm guard not being applied as ordered. The DON confirmed that there were multiple occasions where there was no documentation to support that Resident 35's received their established Restorative Nursing Programs. In addition, the DON confirmed that she would expect staff to have provided Resident 35 their programs and to have applied that their palm guard as ordered. Review of Resident 40's clinical record revealed diagnoses that included muscle weakness and contracture (when muscles or joints tighten or shorten reducing your range of motion). Review of Resident 40's occupational therapy discharge summary on November 3, 2023, revealed he was discharged from therapy services on that date and referred to a RNP program. Review of Resident 40's care plan revealed a focus area of At risk for loss of range of motion related to physical limitations, created on October 14, 2020, with an intervention for Restorative Passive ROM: to bilateral hands (5 reps, twice a day) as tolerated, during care, last revised November 18, 2024. Review of Resident 40's clinical record failed to reveal documentation noting Resident 40's RNP program minutes or tolerance. During an email correspondence with the DON on January 15, 2025, at 9:27 AM, she revealed Resident 40's RNP program was 'corrected.' Interview with Employee 11 (Licensed Practical Nurse) on January 16, 2025, at 10:51 AM, revealed the facility had a change in electronic systems, which caused Resident 40's RNP program to not automatically carry over to documentation, so his RNP program documentation was not captured for the duration of the program. During an interview with the DON on January 16, 2025, at 12:20 PM, she revealed she would expect RNP program minutes and tolerance to be documented per facility policy. Review of Resident 50's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, muscle weakness, and other abnormalities of gait and mobility. Review of Resident 50's care plan revealed a care plan focus for being at risk for loss of range of motion related to physical limitations last revised on August 14, 2024, with interventions that included Restorative Active Range of Motion to right upper extremity before every meal 2 sets of 5 repetitions revised November 5, 2024; Restorative Passive Range of Motion to left upper extremity with ADL's/Care 2 sets of 5 repetitions, revised November 5, 2024. Review of Resident 50's care plan also revealed a care plan focus for ADL self-care deficit evidenced by weakness related to physical limitations revised August 14, 2024, with interventions that included Restorative Bed Mobility: Moderate assist with moving to and from lying position, Moves side to side, while in bed revised May 22, 2024; Restorative Active-Assisted Range of Motion to lower extremities 2 sets of 5 repetitions with moderate assist, dated September 24, 2024; and Restorative Transfer: Transfer from bed to chair, Transfer from w/c [wheelchair]to standard chair, Transfer from chair to bed, Transfer to/from shower chair extensive assist of 2 dated September 24, 2024. Review of Resident 50's Restorative Nursing Program documentation from November 1, 2024, through January 15, 2025, revealed the following: Restorative Bed Mobility, both Restorative Range of Motion programs, and Restorative Transfers were blank on day shift on December 4, 9, 13, 18, 24, and 26, 2024; were blank on evening shift December 30, 2024; were blank on day shift on January 3 and 6, 2025; and were blank on evening shift on January 12, 2025. During a staff interview with the NHA and DON on January 16, 2025, at 12:21 PM, the DON confirmed that there were multiple occasions where there was no documentation to support that Resident 50 received their established Restorative Nursing Programs and that she would expect staff to have provided Resident 50 their programs. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure treatment and services, consistent with professional standards, to promote healing and prevent infection for two of six residents reviewed for pressure ulcers (Residents 16 and 325). Findings include: Review of facility policy, titled NSG236 Skin Integrity and Wound Management, with a last reviewed and revised date of October 15, 2024, revealed 6. The licensed nurse will: 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with any unanticipated decline in wounds. Review of Resident 16's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Review of Resident 16's clinical record revealed that they were transferred to the hospital on January 9, 2025, to be evaluated for mental status change, nausea, vomiting, and not eating. Review of Resident 16's physician orders at time of hospital transfer revealed an order for Wound on sacral area: Cleanse with wound cleanser, pat dry and apply medihoney and foam border dressing. Change every other day or as needed for soilage or dislodgement, dated November 26, 2024. Review of Resident 16's clinical record progress notes revealed a nursing note by a Licensed Practical Nurse dated September 27, 2024, at 12:16 PM, that indicated the Resident was noted to have open area in buttock, and noted blood, saw it small open wound on middle sacrum and that the Registered Nurse Supervisor and was notified and a note was placed on the doctor's book. Review of Resident 16's clinical record progress notes revealed a nursing note by a Registered Nurse dated September 27, 2024, at 1:02 PM, that indicated that a wound care order was obtained. The note further indicated Wound and skin system is down, unable to take new pictures currently will follow up. Review of Resident 16's clinical record revealed a wound specialist consultation note dated October 1, 2024, that indicated that the Resident was consulted for wound prevention. The note further indicated There is no inflammation, rash, wounds, or other lesions of significance. Review of Resident 16's clinical record progress notes revealed a nursing note by a Registered Nurse dated October 10, 2024, at 3:39 PM, indicated the Resident does get small sore area in the sacrum due to [their] incontinence, current treatment with medihoney and covered dressing. Review of Resident 16's Skin and Wound Evaluations revealed that wound evaluations and pictures of their Stage 2 pressure injury were documented on August 23 and 30, 2024; September 5, 2024; October 1 and 8, 2024; November 5 and 29, 2024; and December 10, 2024. All documented evaluations indicated that the wound was stable or improving. Review of Resident 16's Treatment Administration Records from September 2024 through January 8, 2024, revealed that all ordered treatments were provided except when Resident 16 refused. Resident 16 had refused wound care on January 7 and 8, 2024, and that wound care was not provided prior to their transfer to the hospital for an acute change in condition on January 9, 2024. Review of Resident 16's hospital records dated January 9, 2025, indicated that the Resident had chronic sacral wound(s) buttock avulsion (wound in which skin layers are missing) from being in a moist environment and a pressure ulcer. The wound was described as having approximated edges; being brown, red, yellow in color; with a foam dressing in place that was dry. No measurements or staging of the wound was documented. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 16, 2025, at 9:42 AM, the DON indicated that she had no additional information to provide regarding Resident 16's pressure ulcer. In addition, she confirmed that weekly wound evaluations to include measurements were not completed as per facility policy and that she would expect them to be completed weekly and documented. Review of Resident 325's clinical record on January 13, 2025, revealed diagnoses that included stage two chronic kidney disease (decreased ability of kidneys to filter toxins from the blood) and diabetes mellitus type II (decrease in the body's ability to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 325's clinical record section, titled Wound Evaluation, revealed that an assessment by facility staff on January 8, 2024, revealed Resident 325 had a stage 3 pressure ulcer (wound that extends below the skin to the underlying tissue but does not expose bone or connective tissue) to the sacrum which was present upon admission. Review of facility policy, titled IC308 Enhanced Barrier Precautions, last reviewed October 15, 2024, revealed it stated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of novel or multi-drug resistant organisms. It employs targeted personal protective equipment (PPE) use during high contact patient/resident [sic] activities. Further review of the policy revealed it stated that the facility would implement enhanced barrier precautions when a resident, Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any [multi-drug resistant organism]. During observation directly before wound dressing change observation for Resident 325 on January 15, 2025, at approximately 1:00 PM, it was observed that posted on the wall outside Resident 325's room was a sign which indicated that enhanced barrier precautions were in effect for a resident(s) inside the room (Resident 325). The sign included instructions to utilize personal protective equipment with care (gloves, gown, face mask). Under the sign it was observed that a multi-drawer tote was placed which contained gloves, N-95 masks, and gowns. During wound dressing observations for Resident 325 on January 15, 2025, at approximately 1:10 PM, Employee 9 was observed performing a dressing change on Resident 325's stage three pressure ulcer without wearing a gown as indicated for enhanced barrier precautions. During a staff interview on January 16, 2025, at approximately 11:00 AM, DON revealed Employee 9 should have had a gown on, per enhanced barrier precautions, while performing the wound dressing change for Resident 325. During wound dressing observations for Resident 325 on January 15, 2025, at approximately 1:10 PM, Employee 9 was observed performing hand hygiene and then donning gloves prior to the dressing change. After donning gloves, Employee 9 was observed preparing the dressing change area during which Employee 9 was observed using her gloved hand to touch Residents 325 used bed linen (unclean surface), the incontinence brief that Resident 325 was wearing, and used each gloved hand to grab and slightly raise the sleeves of the shirt Employee 9 was wearing (unclean surface). Employee 9 was then observed removing Resident 325's prior dressing without performing hand hygiene and placing new, clean gloves on. After cleansing the wound, Employee 9 was observed preparing a new dressing for Resident 325's pressure ulcer. Employee 9 was observed using her gloved hands to retrieve a marker to write her initials and date on the new dressing. The marker was observed to be retrieved from the top of the medication cart, which was in the hallway, prior to the dressing change. Employee 9 did not cleanse the marker prior to handling it with her gloved hands. After marking the new dressing, Employee 9 put the marker in her pocket. Employee 9 was then observed placing the new dressing over Resident 325's wound. Employee 9 did not perform hand hygiene or change gloves after handling the unclean marker. During a staff interview on January 16, 2025, at approximately 11:00 AM, DON revealed it was the facility's expectation that Employee 9 would have performed hand hygiene and changed gloves after touching unclean surfaces and prior to accessing Resident 325's wound dressing. During the interview, DON confirmed that Employee 9 should have performed hand hygiene and changed gloves after handling the marker that was not cleansed with an anti-microbial agent. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for three of 24 residents reviewed (Residents 20, 35, and 101). Findings include: Review of facility policy, titled NSG200 Activities of Daily Living (ADLs) [Activities of daily living or ADLs are routine tasks that each of us must perform every day to care for our bodies and ourselves independently] dated June 1, 1996, with a revision date of May 1, 2023, and a last review date of October 15, 2024, revealed 1. Patients are assessed upon admission, quarterly, and with any significant change to identify their status in all areas of ADL's and 4.2 A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 20's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side, aphasia (language disorder that affects a person's ability to communicate), and vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults). Observation during lunch meal service on January 13, 2025, at 12:19 PM, revealed Employee 8 (Nurse Aide) placed Resident 20's tray on her tray table in front of her, left it covered and not set-up, and did not return to provide feeding assistance until 12:39 PM. Review of Resident 20's clinical record revealed she required substantial/maximal assistance with eating. Review of Resident 20's care plan revealed a focus area of ADL Self-care deficit as evidenced by right sided weakness and generalized weakness related to recent and previous strokes, last revised August 26, 2024, with an intervention for Assist with daily hygiene, grooming, dressing, oral care and eating as needed, last revised on January 30, 2024. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 16, 2025, at 9:25 AM, the surveyor revealed the concern with the process of nursing staff providing a meal tray to a resident 20 minutes prior to being able to provide feeding assistance. The NHA confirmed that staff should not have provided the meal tray to Resident 20 until they were able to provide feeding assistance. Review of Resident 35's clinical record revealed diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, aphasia, and vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults). Observation of Resident 35 on January 13, 2025, at 9:41 AM, revealed the presence of dark facial hair on her upper lip and chin. Review of Resident 35's care plan revealed a focus for ADL self-care deficit related to physical limitations, with a revised date of November 7, 2024. Interventions included, but were not limited to, assist with bathing/showering, frequently refuses shower, prefers bed bath, will continue to offer shower, daily hygiene, grooming, dressing, oral care and eating as needed, with a revised date of March 19, 2024; and assist of 2 with ADL's, with a revised date of July 10, 2024. Review of Resident 35's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of November 2, 2024, revealed in Section GG Functional Abilities, in subsection 0310 Self-Care at Question I Personal Hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) that she was coded as dependent. During a follow-up observation of Resident 35 on January 14, 2025, at 1:30 PM, revealed the same observation of the presence of moderate dark facial hair on her upper lip and chin. During an immediate interview with Resident 35 when asked if she would like to be shaved, Resident 35 rubbed her chin with her left hand and mouthed the word yes while also nodding her head yes. Review of Resident 35's task documentation for bathing/showering for the past 30 days revealed that she had received a bed bath on December 16, 19, 23, 26, and 30, 2024, and January 2, 6, and 13, 2025. During a staff interview with the NHA and DON on January 15, 2025, at 11:00 AM, the DON indicated that shaving would only be completed if a resident requested it to be done. Observation of Resident 35 on January 16, 2025, at 9:02 AM, revealed that she had been shaved. Resident 35 was observed to rub her chin with her left hand and smile when asked about being shaved. During a final interview with the NHA and DON on January 16, 2025, at 12:21 PM, the DON confirmed that staff should have offered Resident 35 to be shaved as part of her ADL care since the Resident she was dependent for care. Review of Resident 101's clinical record revealed diagnoses that included muscle wasting and atrophy (loss of muscle mass) and Alzheimer's disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Observation of Resident 101 on January 13, 2025, at 12:19 PM, revealed she had three-quarters of an inch facial hair on her chin. Follow-up observations on January 14, 2025, at 9:45 AM, and January 15, 2025, at 9:25 AM, revealed the same observations of three-quarters of an inch facial hair on her chin. Review of Resident 101's task documentation for bathing/showering revealed that she had received a shower on January 13, 2025, at 2:32 PM. Review of Resident 101's care plan revealed a focus area Resident/Patient is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Delirium (confusion), behavioral symptoms last revised December 11, 2024, with an intervention for ADL: 1 Assist created on December 11, 2024. During a final interview with the NHA and DON on January 16, 2025, at 9:26 AM, the DON revealed that staff offered to shave her on January 15, 2025, and they should have offered it during her shower as part of her ADL care. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical needs regarding the interpretation of an electrocardiogram for one of 111 residents reviewed (Resident 1) which resulted in harm to the resident, who was actively having a [MEDICAL CONDITION] and required an admission to the hospital. This failure placed 110 residents (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74 ,75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, and 111) at risk for harm and an Immediate Jeopardy situation. Findings include: Review of the agreement (contract) dated (MONTH) 1, 2014, to provide services between the nursing home and the vendor, revealed a section titled Vendor's Duties. This section revealed the vendor will, provide center (nursing home) with complete, accurate, and timely services upon the request of the center in accordance with the orders of a patient's attending physician. The vendor will perform services in accordance with currently accepted professional standards and all applicable federal, state, and local laws and administrative regulations. Review of Resident 1's clinical record revealed she was admitted to the facility on (MONTH) 13, 2013, with current [DIAGNOSES REDACTED]. Review of Resident 1's (MONTH) 2019 progress notes revealed a note dated (MONTH) 3, 2019, at 11:19 PM by Registered Nurse (RN) 1, Resident approached the desk not feeling well having bilateral arm and back pain. Came on suddenly, pale in color and short of breath when ambulating. Vitals (vital signs) 96.8 (temperature), 148/86 (blood pressure), 74 (pulse), 20 (breaths per minute), 93% on room air (oxygen level). Denies any other complaints, previous shift gave resident Tylenol at 2230 (10:30 PM). CRNP (Certified Registered Nurse Practitioner- an advance practice registered nurse who provides care to residents) with (medical providers group) made aware of condition. New orders; vitals every 4 hours times 24 hours, STAT (immediate), CBCD (complete blood count with differential, a blood test that gives the physician detailed information about the cells in the patient's blood.), CMP (comprehensive metabolic panel-a blood test that gives physicians information about the body's fluid balances and electrolytes), and EKG (electrocardiogram, a recording of the electrical activity of the heart) in the AM. Any changes in pain, nausea, or diaphoresis (sweating) notify (medical providers group). An additional progress note written by RN 1, dated (MONTH) 3, 2019, at 11:39 PM revealed Notified CRNP of (provider group) of continued request for pain medicine due to pain in arms and back. New order: [MEDICATION NAME] 5 mg (milligram, a unit of measure) times one. Awaiting authorization from pharmacy. A progress note written by Licensed Practical Nurse (LPN) 1, dated (MONTH) 4, 2019, at 12:32 AM revealed the medication was administered at 12:30 AM and the vendor had been called for STAT (immediate) EKG. The note also revealed that the vendor was currently in the facility at the time the note was written. An EKG strip was left with the facility at the time the diagnostic test was performed; however, the strip did not have a diagnostic interpretation attached. The progress notes by LPN 1, dated (MONTH) 4, 2019, at 3:29 AM revealed that the EKG results were still pending (no results from the vendor at that time). Review of a progress note by RN 2, dated (MONTH) 4, 2019, at 8:15 AM revealed received stat EKG with critical abnormal-showed acute inferior MI (a [MEDICAL CONDITION]), assessment completed continues with complaint of severe back pain pressure like, denies chest pain, denies SOB (short of breath) but with observation respirations rapid and shallow, heart rate irregular via auscultation (listening), no cyanosis (bluish or purplish discoloration of the skin when the tissues have low oxygenation) noted, radial pulse (pulse at the inside of the wrist) irregular, discussed with CRNP and both attempted to call husband with no answer, sent to (hospital) ER for eval due to MI ([MEDICAL CONDITION]), report called to (Hospital). Review of Resident 1's clinical record revealed a form titled EKG Interpretation, signed by a cardiologist from the vendor (MONTH) 4, 2019, at 6:58 AM revealed that Resident 1's EKG had been performed approximately 12:30 AM on (MONTH) 4th, 2019, was interpreted by the cardiologist at approximately 6:58 AM revealing a right bundle branch block (a blockage of the electrical impulses on the right side electrical conduction system to the heart). Acute inferior [MEDICAL CONDITION] infarction (a coronary artery occlusion with resultant decreased blood/oxygen flow to the heart muscle). The CRNP ordered the STAT EKG at approximately 11:19 PM on (MONTH) 3, 2019, and the facility did not receive the results from this vital diagnostic test until 6:58 AM on (MONTH) 4, 2019, while Resident 1 was having a [MEDICAL CONDITION] in the facility and experiencing pain and decreased oxygenation to the heart muscle. There was no documentation of the staff calling the lab or notifying the CRNP of the delay in results. This lack of action on the part of the facility resulted in actual harm to Resident 1, as the delay in treatment of [REDACTED]. On (MONTH) 14, 2019, at 12:38 PM the Nursing Home Administrator (NHA) was informed of Immediate Jeopardy at the facility and the request for a written correction action plan. The correction action plan was accepted on (MONTH) 14, 2019, at 8:00 PM and included the following: - Effective (MONTH) 6, 2019, ManorCare-Camp[NAME]QAPI Committee under the direction of the Medical Director has determined that the center will not offer STAT EKG services. - Facility Registered Nurses, Licensed Practical Nurses and facility attending physicians, including the Medical Director, have been educated that the facility will not offer STAT EKG services. Education also included that if a physician orders [REDACTED]. - Education outline included the following: - No STAT EKGs will be performed in facility. - Physicians wanting residents to have a STAT EKGs will need to transfer to hospital for tests. - Change in condition procedure from Nursing Manual. - Education was conducted on (MONTH) 30, 2019. - Immediate education to be conducted with RNs and LPNs. - When receiving a STAT order for lab or diagnostic tests, nursing staff will inform physician of the contract terms of STAT timeframe. If the physician is not in agreement of the STAT timeframe an order will be obtained to transfer resident to hospital. - Ongoing compliance will be monitored by the Director of Nursing/designee using the laboratory and diagnostic services audit tool through five audits of residents weekly x 4 weeks and monthly x 2 to ensure timely completion of STAT tests. Audit results will be reported to the QAA committee and the QAA committee will determine the need for further audits. Physician will be notified of any negative audit findings such as missing labs or diagnostic services for further direction and/or orders. On (MONTH) 15, 2019, at 11:45 AM the NHA was notified that the Immediate Jeopardy was lifted. The facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical needs regarding the interpretation of an electrocardiogram for one resident which resulted in harm to the resident that was actively having a [MEDICAL CONDITION]. This failure also placed other residents with potential abnormal findings for STAT studies at risk for harm of death due to the failure to receive timely care and services to prevent injury, serious harm, or death. 42 CFR 483.25 Quality of Care. Previously cited 3/20/19, 6/7/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/9/19, 6/7/18. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 5/9/19, 6/7/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 6/7/18. 28 Pa. Code 201.29(a)(d) Resident rights. Previously cited 6/7/18. 28 Pa. Code 211.10(a)(b)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 6/12/19, 5/9/19, 3/20/19, 6/7/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 5/9/19.