Every finding on record at Canterbury Place

Based on review of facility policy, resident clinical records, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments and document treatments that are consistent with professional standards of practice to promote healing of a pressure ulcer for three of three sampled resident records (Residents R7, R8, and Resident R9). Findings include: The facility Wound care policy last reviewed 12/9/25, indicated that wound documentation should be recorded in the resident's medical record and include the following information:-The type of wound care given.-The date and time the wound care was given.-The position in which the resident was placed.-The name and title of the individual performing the wound care.-Any change in the resident's condition.-All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.-How the resident tolerated the procedure.-Any problems or complaints made by the resident related to the procedure.-If the resident refused the treatment and the reason(s) why.-The signature and title of the person recording the data.-and report to the supervisor if the resident refuses the wound care and any other information in accordance with facility policy and professional standards of practice. Review of Resident R7's admission record indicated he was admitted on [DATE]. Review of Resident R7's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 6/29/26, indicated he had diagnoses that included dysphagia (difficulty swallowing), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination). Review of Resident R7's care plans dated 6/30/26, indicated he had a buttocks wound and to measure the ulcer on at regular intervals. Review of Resident R7's wound consultant note dated 7/28/26, indicated Resident R7 had a sacral pressure injury, Stage-3, measuring 2.0 cm x 1.60 cm x 0.1 cm, small Sero-sanguineous (fluid exiting wound area) drainage. The consultant notes also indicated Resident R7 had a right buttock pressure injury, measuring 0.4 cm x 0.5 cm x 0.1 cm, with small drainage. Review of Resident R7's clinical social service note dated 7/31/26, indicated wound team will see him Tuesday and therapy is willing to keep Resident R7 on and keep working with him he is making progress. Review of Resident R7's clinical nurse notes, skin check documentation, consultation documentation and physician notes did not include weekly comprehensive assessments after 7/28/26 that included measurements, treatments, change in condition, and if Resident R7 tolerated the treatments. Review of Resident R8's admission record indicated he was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident R8's MDS assessment dated [DATE], indicated that he had diagnoses that included multiple sclerosis (MS: a disruption in the central nervous system causing inflammation and impacting communication with the nervous system), muscle weakness and diabetes. Review of Resident R8's care plans dated 7/22/26, indicated to provide wound management and to measure the ulcer on at regular intervals. Review of Resident R8's wound consultant documentation dated 7/28/26, indicated Resident R8 had a chronic Stage-4 Pressure Injury to the Sacral area and it measured at 1.3 cm x 1.9 cm x 2 cm. Review of Resident R8's clinical nurse notes, consultation documentation, and physician notes did not include weekly comprehensive assessments after 7/28/26 that included measurements, treatments, change in condition, and if Resident R8 tolerated the treatments. Review of Resident R8's physician orders dated 7/28/26, indicated to provide the following:Sacral, Pressure Injury: Cleanse with Normal Saline Solution and pack with Silver Alginate, Triad to Peri-wound and cover with foam dressing. Change Daily and as needed. Review of Resident R8's August 2026 Medication Administration Record (MAR) did not include administration of the Sacral wound treatment on the following dates: 8/6/26 Review of Resident R9's admission record indicated she was originally admitted on [DATE]. Review of Resident R9's MDS assessment dated [DATE], indicated that she had diagnoses that included gout (a form of arthritis involving severe pain) and hypertension (a condition impacting blood circulation through the heart related to poor pressure), and muscle weakness. Review of Resident R9's care plan dated 6/30/26, indicated to provide wound management and to measure the ulcer on at regular intervals. Review of Resident R9's wound consultant documentation dated 7/28/26, indicated Resident R9 had a Stage-2 Pressure Injury to the Sacral area, and it measured 0.8 cm x 0.8 cm x 0.1 cm. Review of Resident R9's nurse note dated 8/4/26, indicated that Resident R9 skin issue has not been evaluated. Review of Resident R9's clinical nurse notes, consultation documentation, and physician notes did not include weekly comprehensive assessments after 7/28/26 that included measurements, treatments, change in condition, and if Resident R8 tolerated the treatments. Review of Resident R9's physician orders dated 7/28/26, indicated to provide the following:Sacral, Pressure Injury: Cleanse with Normal saline solution, pat dry, apply medical grade honey to wound bed, cover with bordered gauze. Change Daily and as needed. Review of Resident R9's August 2026 Medication Administration Record (MAR) did not include administration of the Sacral wound treatment on the following dates:8/4/26, 8/5/26, 8/10/26, and 8/11/26. During an exit interview on 8/13/26, at 11:06 a.m. the Director of Nursing (DON) was asked for the location of the weekly wound assessments, and she stated: the weekly assessments are in the computer system; if the resident is not seen by wound consultant, then the nurse should complete a weekly wound assessment. The wound consultant has not been in the facility. During an exit interview on 8/14/26, at 11:45 a.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to provide comprehensive skin assessments and document treatments that are consistent with professional standards of practice to promote healing of a pressure ulcer for Residents R7, R8, and Resident R9 as required. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area in one of four nursing units (First-floor nursing unit).Findings include: The facility Resident Call system policy last reviewed 12/9/25, indicated that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. During observations of the first floor on 8/12/26, call bells observations found the following: -at 10:35 a.m. Resident R9's call bell was observed activated. The indicator light above her room was lit. Observations at the nurse station found the Monitor off, no auditory or visual indication at nurse station that Resident R9's call bell was activated. During an interview on 8/12/26, at 10:40 a.m. Licensed Practical Nurse (LPN) Employee E1 was asked about the call light system at the nurse station not working, she stated: I'm not sure why it's not working. During an interview on 8/12/26, at 11:06 a.m. interview with Director of Maintenance Employee E2 was asked about the call bell indicator at nurse station on first floor and he stated: there is no volume at the nurse station. One of the desks does not function. That went down some time last week. During an exit interview on 8/14/26, at 11:45 a.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for the first-floor nursing unit as required. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station

Based on the review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to appropriately document skin evaluations for two of four sampled resident records (Residents R1 and Resident R5).Findings include: The facility Charting and documentation policy last reviewed 12/9/25, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:-Objective observations-Medications administered-Treatments or services performed Review of Resident R1's admission record indicated she was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/23/26, indicated she had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and an anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Resident R1's care plans dated 3/23/26, indicated to provide skin inspections to Resident R1. Resident R1 required one person assist for skin inspection twice weekly on Wednesday and Saturday 3-11 shift. Observe skin for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of Resident R1's weekly skin integrity review (a form with documented skin evaluation observations) dated 6/13/26, indicated skin was intact. Review of Resident R1's clinical nurse notes and physician documentation did not include weekly skin evaluations until 8/10/26. Review of Resident R5's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R5's MDS assessment dated [DATE], indicated that she had diagnoses that included anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and protein malnutrition. Review of Resident R5's care plan dated 1/2/26, and revised on 8/4/26, indicated to provide skin inspections to Resident R5. Resident R5 required one person assist for skin inspection twice weekly on Wednesday and Saturday 3-11 shift. Observe skin for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of Resident R5's weekly skin integrity review dated 6/16/26, indicated skin was intact. Review of Resident R5's clinical nurse notes, consultation documentation and physician documentation did not include weekly skin evaluations. During an interview on 8/13/26, at 2:07 p.m. Registered Nurse (RN) Employee E5 asked about skin checks documentation: skin checks are done when a resident has a shower. That is different from a skin assessment. During an interview on 8/13/26, at 2:10 p.m. Registered Nurse (RN) Employee E6 was asked how skin checks are done? Nurse aides do a skin check sheet on shower days. The sheet is also done on admission. During an interview on 8/13/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that the facility failed to appropriately document skin evaluations for Resident R1 and Resident R5 as required. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of facility policy, resident clinical records, resident and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors and provided medication timely for two of four sampled resident records (Resident R3 and R4).Findings include: The facility Medication pass last reviewed 12/9/25, indicated that medication pass times are as follows for each nursing unit: 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. The facility Charting and documentation policy last reviewed 12/9/25, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:-Objective observations-Medications administered-Treatments or services performed Review of Resident R3's admission record indicated he was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident R3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 6/28/26, indicated he had diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), history of falling, and epilepsy (a long-term disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells). Review of Resident R3's care plans dated 6/25/26, indicated to administer medications as ordered. Review of Resident R3's physician orders indicated to administer the following medications:-Folic Acid Oral Tablet 1 mg, give 1 tablet by mouth one time a day- Furosemide Oral Tablet 40 mg, give 1 tablet by mouth one time a day- Jardiance Oral Tablet 10 mg, give 1 tablet by mouth one time a day- Polyethylene Glycol 3350 Powder, give 17 gram by mouth one time a day- Sertraline HCl Oral Tablet 25 mg, give 1 tablet by mouth one time a day - Spironolactone Oral Tablet 25 mg, give 1 tablet by mouth one time a day- Carvedilol Oral Tablet 3.125 mg, give 1 tablet by mouth every morning and atbedtime- Entresto Oral Tablet 24-26 mg, give 1 tablet by mouth every morning and atbedtime for- Keppra Oral Tablet 750 mg, give 2 tablet by mouth every morning and atbedtime- Lacosamide Oral Tablet 50 mg, give 1 tablet by mouth every morning and atbedtime- Magnesium Oxide Oral Tablet 400 mg, give 1 tablet by mouth every morning and atbedtime Review of Resident R3's August 2026 Medication Administration Record (MAR) did not include an administration of the following medications on the morning of 8/12/26:-Folic Acid Oral Tablet 1 mg, give 1 tablet by mouth one time a day- Furosemide Oral Tablet 40 mg, give 1 tablet by mouth one time a day- Jardiance Oral Tablet 10 mg, give 1 tablet by mouth one time a day- Polyethylene Glycol 3350 Powder, give 17 gram by mouth one time a day- Sertraline HCl Oral Tablet 25 mg, give 1 tablet by mouth one time a day - Spironolactone Oral Tablet 25 mg, give 1 tablet by mouth one time a day- Carvedilol Oral Tablet 3.125 mg, give 1 tablet by mouth every morning and atbedtime- Entresto Oral Tablet 24-26 mg, give 1 tablet by mouth every morning and atbedtime for- Keppra Oral Tablet 750 mg, give 2 tablet by mouth every morning and atbedtime- Lacosamide Oral Tablet 50 mg, give 1 tablet by mouth every morning and atbedtime- Magnesium Oxide Oral Tablet 400 mg, give 1 tablet by mouth every morning and atbedtime Review of Resident R4's admission record indicated she was admitted on [DATE]. Review of Resident R4's MDS assessment dated [DATE], indicated she had diagnoses that include epilepsy, muscle weakness and an anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Resident R4's care plan dated 7/14/26, indicated to administer medications as ordered by the physician. Review of Resident R4's physician orders indicated to administer the following medications:-Cholecalciferol Oral Tablet, give 25 mcg by mouth one time a day- Ferrous Sulfate Oral Tablet, give 325 mg by mouth one time a day- Loratadine Oral Tablet, give 10 mg by mouth one time a day- MiraLAX Powder, give 17 gram by mouth one time a day- Potassium Chloride Oral Tablet Extended Release 20 MEQ, give 1 tablet by mouth one time a day- Senna Tablet, give 17.2 mg by mouth one time a day- Tamsulosin HCl Oral Capsule, give 0.8 mg by mouth one time a day- Wellbutrin SR Oral Tablet Extended Release 12 Hour, 150 mg, give 1 tablet by mouth one time a day- Topiramate Oral Tablet, give 50 mg by mouth two times a day Review of Resident R4's August 2026 Medication Administration Record (MAR) did not include an administration of the following medications on the morning of 8/12/26:-Cholecalciferol Oral Tablet (Cholecalciferol), give 25 mcg by mouth one time a day- Ferrous Sulfate Oral Tablet (Ferrous Sulfate), give 325 mg by mouth one time a day- Loratadine Oral Tablet (Loratadine) give 10 mg by mouth one time a day- MiraLAX Powder (Polyethylene Glycol 3350) give 17 gram by mouth one time a day- Potassium Chloride Oral Tablet Extended Release 20 MEQ, give 1 tablet by mouth one time a day- Senna Tablet, give 17.2 mg by mouth one time a day- Tamsulosin HCl Oral Capsule, give 0.8 mg by mouth one time a day- Wellbutrin SR Oral Tablet Extended Release 12 Hour, 150 mg, give 1 tablet by mouth one time a day- Topiramate Oral Tablet, give 50 mg by mouth two times a day During an interview on 8/12/26, at 11:20 a.m. Resident R4 was observed out of bed and she stated: I did not get my morning medications. During observations of the nursing unit on 8/12/26, at 11:21 a.m. Licensed Practical Nurse (LPN) Employee E1 was seen still passing medications on the first-floor medication cart. During an interview on 8/12/26, at 11:24 a.m. interview with Licensed Practical Nurse (LPN) Employee E1 was asked if there were still resident rooms that did not get medications, and she stated: Yes. I still have to pass medications to Resident R3's room and Resident R4's room. Been a little hectic this morning. During an interview on 8/12/26, at 11:36 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that residents were free from significant medication errors and provided medication timely for Resident R3 and Resident R4 as required. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to administer appropriate respiratory care for one of three sampled residents (Resident R1). Findings include: The facility Administering Medications through a Small Volume Nebulizer policy last reviewed 12/9/25, indicated that the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Document the following information and it should be recorded in the resident's medical record: the name, title and initials of the person administering the treatment, the date, time and length of treatment (treatment administration record), the type and amount of medication administered (medication administration record), the type and source of gas, the pulse, respiratory rate and lung sounds before and after the treatment, the pulse during treatment, the amount and characteristics of sputum production, the resident's tolerance of the treatment, any adverse effects of the medication and/or treatment and physician notification, and reporting/notify the Nurse Supervisor (or the physician) if the resident refuses the treatment. Review of Resident R1's admission record indicated she was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/23/26, indicated she had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and an anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Resident R1's care plans dated 5/26/26, indicated Resident R1 has COPD, administer nebulizer treatment as ordered, monitor for breathing difficulty, and to give aerosol as ordered. Review of Resident R1's physician order dated 1/27/26, indicated to administer Ipratropium- Albuterol Solution (breathing treatment) (3) mg/3ml, one vial, inhale orallyfour times a day. Review of Resident R1's of July 2026 Medication Administration Record (MAR) found the Ipratropium- Albuterol Solution was not administered on the following dates:-7/3/26, 4:00 p.m. -7/11/26, 8:00 p.m. -7/17/26, 8:00 a.m.-7/19/26, 4:00 p.m. Review of Resident R1's physician order dated 1/27/26, indicated to administer Budesonide Suspension (breathing treatment) 0.25 mg/2ml, inhale orally every 12 hours. Review of Resident R1's of July 2026 Medication Administration Record (MAR) found the Budesonide Suspension was not administered on the following dates:-7/11/26, 8:00 p.m.-7/17/26, 8:00 a.m. During an interview on 8/13/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that the facility failed to administer appropriate respiratory care for Resident R1 as required. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident records, facility grievance documents, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of negligence for one of three sampled records (Resident R2).Findings include: The facility Abuse and neglect policy last reviewed 12/9/25, indicated that the management and staff will address situations of suspected or identified abuse and report them in a timely manner to the appropriate agencies, consistent with applicable laws and regulations. The facility Guidelines for Initial Reporting of Resident Incidents and Accidents for Health Center policy last reviewed 12/9/25, indicated that Abuse, neglect, exploitation,misappropriation allegations are reported immediately. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/19/26, indicated she had diagnoses that included subdural hemorrhage (a collection of blood between the brain and outer covering related to head trauma), muscle weakness, and dysphagia (difficulty swallowing). Review of grievance dated 8/5/26, indicated that an Adult Protective Services (APS) called in anonymous complaint alleging negligence involved Resident R2. The allegation included Resident R2 was getting sleeping pills at 4:30 p.m., not having bloodwork done, not having a head imaging completed, and her family unable to contact Resident R2. Review of reported incidents of abuse and negligence to the State did not include Resident R2's negligence allegations. During an interview on 8/12/26, at 10:38 a.m. Social worker Employee E4 was asked why Adult Protective Services (APS) was in facility on 8/5/26, and if the person in the grievance is an APS investigator, Social worker Employee E4 stated: that is an APS investigator. He called us on an anonymous report about Resident R2. She is still here. There was an allegation call from someone that there was no blood work completed, no one spoke to her, and she was getting sleeping pills. During an interview on 8/12/26, at 11:06 a.m. information disseminated to the Director of Nursing (DON) that the facility failed to submit a report of an allegation of negligence related to Resident R2 as required. During an exit interview on 8/14/26, at 11:45 a.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to submit a report of an allegation of negligence related to Resident R2 as required. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy and facility job descriptions, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R1).Findings include: Review of facility policy Skin Care and Wound Management dated 12/9/25, indicated all residents have head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented in the electronic medical record NRSG: Weekly Skin. Assigned/due treatments are assigned in the electronic medical record under the ETAR (Electronic Treatment Administration Record) tab. Wound assessments/observation are required at a minimum weekly and when there is a change. Review of the facility Licensed Practical Nurse (LPN) job description indicated the LPN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments. Review of the facility Registered Nurse (RN) job description indicated the RN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's comprehensive care plan dated 10/14/24, indicated the resident has potential impairment to skin integrity related to immobility, PVD, Sweet syndrome (a rare inflammatory skin disorder characterized by fever and painful, red or purple skin lesions), and incontinence. Interventions include follow facility protocols for treatment of injury. Review of a facility submitted document dated 6/11/26, indicated the following: Nurse practitioner (NP) was in to see Resident R1 after nursing staff reported that resident has a dressing placed to LLE (left lower extremity) skin tear on 5/21 with orders for daily xeroform (a medicated gauze dressing that keeps wounds moist and helps prevent infection) dressing. RN and NP assessed area and found the original one area of ulceration was now a few shallow ones, resident denies pain on assessment. On date, during a routine dressing change, the facility nurse identified that resident's LLE skin tear dressing, originally applied on had not been changed since 5/21/26. Review of the electronic medical record showed that multiple licensed nurses documented that the dressing was changed according to the treatment order during this period. Review of a nursing progress note dated 3/6/26, stated, Patient has, what appears to be a skin tear (a traumatic wound caused by mechanical forces that partially or fully separates the skin layers, often resulting in a skin flap) on left front tibia (shin), below the knee, measures 0.3 cm (centimeters) x 0.3 cm. Appears to have been scratched since obvious dried blood over skin tear. Patient denies pain. No swelling. Very superficial, band aide applied over area. Review of a physician order dated 3/11/26, indicated left lower extremity skin tear - cleanse with soap and water, apply xeroform and dry dressing daily every day shift for skin tear. Review of Resident R1's May 2026 and June 2026 TAR revealed the above treatment documentation:5/21/26: documented completed5/22/26: blank, no documentation to indicate treatment was completed or refused by resident5/23/26: documented completed5/24/26: documented completed5/25/26: documented completed5/26/26: documented completed5/27/26: documented completed5/28/26: documented completed5/29/26: blank, no documentation to indicate treatment was completed or refused by resident5/30/26: not completed due to healed5/31/26: blank, no documentation to indicate treatment was completed or refused by resident6/1/26: documented completed6/2/26: documented completed6/3/26: blank, no documentation to indicate treatment was completed or refused by resident6/4/26: documented completed6/5/26: documented completed6/6/26: documented completed6/7/26: documented completed6/8/26: documented completed6/9/26: documented completed6/10/26: documented completed Review of a Skin/Wound progress note dated 6/16/26, stated, Resident seen by wound team this morning. Healing abrasion (scrape) present to LLE. Wound is dry. No drainage. A couple scabbed areas remain. To apply skin prep (a liquid product used to create a protective barrier) QD (every day) and leave OTA (open to air). Review of a witness statement dated 6/15/26, completed by LPN Employee E2 stated, I inadvertently did not do the wound care on Resident R1's medical record and I accidentally signed off the dressing on the MAR (medication administration record). I had asked oncoming nurse to do dressing. Review of Resident R1's clinical record revealed LPN Employee E2 documented the treatment as completed on 6/10/26. Review of a witness statement dated 6/12/26, completed by LPN Employee E3 stated, That wound was healed and her put a dressing on a healed just a pink area wound made it a wound cause the people that seen it and worked there knew it didn't need anything wrong for signing it but never the less it was healed and when you got the whole floor you're busy no excuse but that's the truth. Review of Resident R1's clinical record revealed LPN Employee E3 failed to document the treatment as completed on 5/31/26, and documented the treatment as completed on 6/7/26. Review of a witness statement dated 6/12/26, completed by LPN Employee E4 stated, Last time I seen it was healed nurses before me can witness. Review of Resident R1's clinical record revealed LPN Employee E4 documented the treatment as completed on 5/25/26, 5/26/26, 5/28/26, 6/1/26, 6/2/26, 6/4/26, 6/5/26, 6/8/26, and 6/9/26. On 5/30/26, LPN Employee E4 documented the treatment as not performed due to the area healed. Review of a witness statement dated 6/16/26, completed by RN Employee E5 stated, There were two dates when RN recorded her initials and did not change dressing. RN either signed while charting with intent to change dressing and forgot or there were two times RN came in to change dressing and had to attend to roommates repositioning and one time when nurse aide refused to clean up roommate who was covered in chocolate. RN will change dressing then sign in chart moving forward. Review of Resident R1's clinical record revealed RN Employee E5 documented the treatment as completed on 5/23/26, and 6/6/26. During an interview on 6/30/26, at 12:30 p.m. RN Employee E6 stated, I would not mark a treatment as completed without actually doing it. During an interview on 6/30/26, at 1:08 p.m. RN Employee E7 stated, I would not sign off a treatment if I did not actually complete it. During an interview on 6/30/26, at 1:10 p.m. RN Employee E8 stated, I would not sign off a treatment as completed if I did not do it. During an interview on 6/30/26, at 1:14 p.m. RN Employee E1, RN Employee E9, and RN Employee E10 all stated, I would not document a treatment a completed without actually completing the treatment. Review of Resident R1's clinical record failed to include documentation that a weekly skin assessment was performed for the following weeks:4/5/26 - 4/11/264/12/26 - 4/18/264/19/26 - 4/25/264/26/26 - 5/2/265/3/26 - 5/9/265/17/26 - 5/23/265/31/26 - 6/6/266/7/26 - 6/13/26 During an interview on 6/30/26, at 1:45 p.m. the Director of Nursing (DON) confirmed that the facility failed to complete and document a weekly skin assessment for Resident R1 on the above-mentioned dates. During an interview on 6/30/26, at 1:45 p.m. the DON confirmed that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy and the Pennsylvania Nursing Practice Act, clinical record review, incidents submitted to the local State field office, and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of clinical practice for one of four residents (Resident R1).Findings include: Review of facility policy Skin Care and Wound Management dated 12/9/25, indicated assigned/due treatments are assigned in the electronic medical record under the ETAR (Electronic Treatment Administration Record) tab. Review of the facility Licensed Practical Nurse (LPN) job description indicated the LPN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments. Review of the facility Registered Nurse (RN) job description indicated the RN is to provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. Responsibilities include sets up and administers prescribed medications and treatments. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.18 Standards of nursing conduct (a)(5) indicates the registered nurse shall document and maintain accurate records. 21.18(b)(8) indicates the registered nurse may not falsify or knowingly make incorrect entries into the patient's record or other related documents. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.148 Standards of nursing conduct (a)(5) indicates a licensed practical nurse shall document and maintain accurate records. 21.148 (b)(8) indicates a licensed practical nurse may not falsify or knowingly make incorrect entries into the patient's record or other related documents. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's comprehensive care plan dated 10/14/24, indicated the resident has potential impairment to skin integrity related to immobility, PVD, Sweet syndrome (a rare inflammatory skin disorder characterized by fever and painful, red or purple skin lesions), and incontinence. Interventions include follow facility protocols for treatment of injury. Review of a facility submitted document dated 6/11/26, indicated the following: Nurse practitioner (NP) was in to see Resident R1 after nursing staff reported that resident has a dressing placed to LLE (left lower extremity) skin tear on 5/21 with orders for daily xeroform (a medicated gauze dressing that keeps wounds moist and helps prevent infection) dressing. RN and NP assessed area and found the original one area of ulceration was now a few shallow ones, resident denies pain on assessment. On date, during a routine dressing change, the facility nurse identified that resident's LLE skin tear dressing, originally applied on had not been changed since 5/21/26. Review of the electronic medical record showed that multiple licensed nurses documented that the dressing was changed according to the treatment order during this period. Review of a nursing progress note dated 3/6/26, stated, Patient has, what appears to be a skin tear (a traumatic wound caused by mechanical forces that partially or fully separates the skin layers, often resulting in a skin flap) on left front tibia (shin), below the knee, measures 0.3 cm (centimeters) x 0.3 cm. Appears to have been scratched since obvious dried blood over skin tear. Patient denies pain. No swelling. Very superficial, band aide applied over area. Review of a physician order dated 3/11/26, indicated left lower extremity skin tear - cleanse with soap and water, apply xeroform and dry dressing daily every day shift for skin tear. Review of Resident R1's May 2026 and June 2026 TAR revealed the above treatment documentation:5/21/26: documented completed5/22/26: blank, no documentation to indicate treatment was completed or refused by resident5/23/26: documented completed5/24/26: documented completed5/25/26: documented completed5/26/26: documented completed5/27/26: documented completed5/28/26: documented completed5/29/26: blank, no documentation to indicate treatment was completed or refused by resident5/30/26: not completed due to healed5/31/26: blank, no documentation to indicate treatment was completed or refused by resident6/1/26: documented completed6/2/26: documented completed6/3/26: blank, no documentation to indicate treatment was completed or refused by resident6/4/26: documented completed6/5/26: documented completed6/6/26: documented completed6/7/26: documented completed6/8/26: documented completed6/9/26: documented completed6/10/26: documented completed Review of a Skin/Wound progress note dated 6/16/26, stated, Resident seen by wound team this morning. Healing abrasion (scrape) present to LLE. Wound is dry. No drainage. A couple scabbed areas remain. To apply skin prep (a liquid product used to create a protective barrier) QD (every day) and leave OTA (open to air). Review of a witness statement dated 6/15/26, completed by LPN Employee E2 stated, I inadvertently did not do the wound care on Resident R1's medical record and I accidentally signed off the dressing on the MAR (medication administration record). I had asked oncoming nurse to do dressing. Review of Resident R1's clinical record revealed LPN Employee E2 documented the treatment as completed on 6/10/26. Review of a witness statement dated 6/12/26, completed by LPN Employee E3 stated, That wound was healed and her put a dressing on a healed just a pink area wound made it a wound cause the people that seen it and worked there knew it didn't need anything wrong for signing it but never the less it was healed and when you got the whole floor you're busy no excuse but that's the truth. Review of Resident R1's clinical record revealed LPN Employee E3 failed to document the treatment as completed on 5/31/26, and documented the treatment as completed on 6/7/26. Review of a witness statement dated 6/12/26, completed by LPN Employee E4 stated, Last time I seen it was healed nurses before me can witness. Review of Resident R1's clinical record revealed LPN Employee E4 documented the treatment as completed on 5/25/26, 5/26/26, 5/28/26, 6/1/26, 6/2/26, 6/4/26, 6/5/26, 6/8/26, and 6/9/26. On 5/30/26, LPN Employee E4 documented the treatment as not performed due to the area healed. Review of a witness statement dated 6/16/26, completed by RN Employee E5 stated, There were two dates when RN recorded her initials and did not change dressing. RN either signed while charting with intent to change dressing and forgot or there were two times RN came in to change dressing and had to attend to roommates repositioning and one time when nurse aide refused to clean up roommate who was covered in chocolate. RN will change dressing then sign in chart moving forward. Review of Resident R1's clinical record revealed RN Employee E5 documented the treatment as completed on 5/23/26, and 6/6/26. During an interview on 6/30/26, at 12:30 p.m. RN Employee E6 stated, I would not mark a treatment as completed without actually doing it. During an interview on 6/30/26, at 1:08 p.m. RN Employee E7 stated, I would not sign off a treatment if I did not actually complete it. During an interview on 6/30/26, at 1:10 p.m. RN Employee E8 stated, I would not sign off a treatment as completed if I did not do it. During an interview on 6/30/26, at 1:14 p.m. RN Employee E1, RN Employee E9, and RN Employee E10 all stated, I would not document a treatment a completed without actually completing the treatment. During an interview on 6/30/26, at 1:45 p.m. the Director of Nursing confirmed that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of clinical practice for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, facility documents, clinical records, and staff interviews it was determined that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility. This failure created an immediate jeopardy situation (IJ) for sixteen residents identified as an elopement risk. The immediate jeopardy was cited as past noncompliance. Findings include: Review of the facility policy Wandering and Elopements dated 12/9/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the facility policy Fire Safety In-Service dated 12/9/25, indicated that in the event of an activated fire alarm all doors that are equipped with electromagnetic hold-open devices automatically close. Security systems on the First Floor and Renaissance Hall (secured memory care unit) automatically are released. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/26, indicated diagnoses of anemia (the blood doesn't have enough healthy red blood cells), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Section B0700 Makes self-understood, indicated rarely/never understood. Section B0800 Ability to understand others, indicated rarely/never understands. Section C1000 Cognitive skills for daily decision making indicated severely impaired - never/rarely made decisions. Review of Resident R1's Elopement Evaluation dated 1/28/26, indicated the following:History of elopement at home: Yes.Wandering behavior, a pattern or goal-directed: No.Wanders aimlessly or non-goal directed: Yes;Wandering behavior likely to affect the safety or well-being of self/others: Yes.Wandering behavior likely to affect the privacy of others: Yes.Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No.Elopement score: Five. High risk for wandering. Review of Resident R1's current care plan indicated resident is at high risk for wandering due to cognitive impairment related to dementia. Goal - resident will remain safe and free from elopement. Interventions - assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Maintain secure environment with doors alarmed and monitored. Respond promptly to wander guard alerts and provide supervision appropriate to assessed risk level while in the dementia unit. Review of Resident R1's progress note dated 4/23/26, at 4:16 a.m. indicated the fire alarm was activated at 11:16 p.m. All doors unlocked. Resident was not accounted for and staff found resident in the courtyard outside approximately 20 minutes later. When staff realized the resident was not in bed and there was a second alarm sounding, this nurse and Nurse Aide (NA) went room to room looking for resident. Staff seen the resident in the courtyard outside of the activity/television room. Resident was observed ambulating and had a scrape noted to the left knee. Area cleaned and left open to air. Supervisor notified immediately. Resident's son made aware and on call physician. Review of facility provided documentation dated 4/22/26, indicated Resident R1 had an unwitnessed exit from building on Wednesday, April 22, 2026, at 11:29 p.m. Resident resides on the Renaissance Hall Unit, and wears a wander guard (a security bracelet that alarms if resident moves near or beyond an alarmed area). At approximately 11:26 p.m. the fire alarm sounded in duct work on the fourth floor of the building; therefore, deactivating locked doors. Fire Department arrived and by 11:40 p.m. determined no fire issues occurred on the fourth floor or within building; therefore, deeming the situation clear. Fire department reset the fire panel. Description of Follow-up Action: At 11:40 p.m. on Renaissance Hall Unit during a head count conducted by the staff, it was determined that the wander guard was alarming and Resident R1 was not accounted for. A search was immediately initiated. Staff saw resident at lounge doors and brought resident inside at 11:54 p.m. without incident. Evaluation by nurse was performed and noted that resident was at baseline for vitals and appearance. Physician and family representative were notified. Education on fire alarm response and egress was initiated on 04/23/26. Review of NA Employee E2's witness statement dated 4/23/26, indicated they were charting when the fire alarm went off at 11:15 p.m. They went down the long hall to put out the checks outside the residents' doors. They sat watch on the doors and the fire department entered. Fire department came back to the unit and said all clear after the noise was over. Upon reopening resident doors, they didn't see Resident R1. They started searching and observed Resident R1 through the patio doors outside in the courtyard. Staff ran and told the nurse, who got the code and brought resident back inside. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement dated 4/23/26, indicated the fire alarm activated at 11:16 p.m. which unlocked all doors. NA Employee E2 and LPN Employee E3 closed resident room doors, and located residents. Resident R1 was not located. Both staff did a second round without success. Resident was found in the courtyard walking around. Review of Registered Nurse (RN) Employee E3's witness statement dated 4/23/26, indicated they were notified by LPN Employee E3 that a resident had gotten outside the facility. They were able to see her from the door and needed the code to the door. The code was provided and resident was assisted into the facility. Review of RN Employee E5's witness statement dated 4/25/26, indicated during shift change report on 4/23/26, from evening shift into night shift, the fire alarm went off, and RN contacted the Maintenance Director. The fire department arrived and the RN left after handing over to the oncoming RN. Interview on 6/2/26, at 11:00 a.m. LPN Employee E9 confirmed Resident R1 eloped during a fire alarm event the night of 4/22/26. That the doors unlock and staff must station themselves at the doors to prevent residents from getting out. Interview and tour with LPN Employee E9 on 6/2/26, at 1:00 p.m. indicated Resident R1's room is in the back hall. The opposite end of the hallway was a set of double fire doors that resident would have gone through, then through a large dining area, around a corner to an exit door that has a key code to the courtyard. The courtyard also has a magnetized locking gate that opens into the front driveway of the facility where there are several parking areas for cars. Interview on 6/2/26, at 1:33 p.m. the Nursing Home Administrator was made aware that Immediate Jeopardy (IJ) was called due to the elopement of Resident R1 on 4/22/26. The NHA was provided with an Immediate Jeopardy template, and a corrective action plan was requested. Review of the facility's immediate action plan on 6/2/26, at 2:35 p.m. indicated the following:-On 4/22/26, at 11:26 p.m. the fire alarm activated on the fourth-floor duct work.-On 4/22/26, at 11:40 p.m. the fire department reset the fire panel after they cleared the building ending the fire alarm announcements and fire bell ringing. At the same time, staff in the Renaissance Hall realized the wander guard was sounding and immediately started to head count for all residents.-Staff realized resident was missing and initiated a search. NA checked the dining room area and the exit door seeing resident in the courtyard closer to the television room doors and ran around to that area to get resident. As NA moved to the television lounge, they notified the nurse that the resident was outside, and they brought resident back in through television lounge doors at 11:54 p.m.-Root cause identified on 4/23/26, that an employee did not station themselves at all exit doors.-Head count was performed at time of elopement, on 4/22/26.-Resident R1 was assessed and within limits on 4/22/26. -Care plan reviewed and every one-hour checks were implemented on 4/22/26.-Doctor was called/notified of elopement on 4/23/26.-Family was notified of elopement on 4/23/26.-Reviewed and revised elopement policy 4/23/26.-Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was performed discussing the event on 4/23/26.-Elopement assessment verified as current and resident actively identified as high risk for elopement, on 1/28/26.-Education was completed for wandering and elopements by 4/26/26. -Monitoring audits of fire drills were completed on four occasions and completed on 5/7/26. On 6/2/26, at 3:45 p.m. the following items have successfully been verified as met per the immediate action plan:-Root cause identified on 4/23/26, that an employee did not station themselves at door during fire drill and magnetic lock release.-Assessment was verified as accurately identifying resident at risk for elopement, dated 1/28/26.-Care plan was verified to be updated with every hour checks implemented on 4/22/26.-Resident was assessed and only a scrape to left knee found. Area cleansed and left open to air on 4/22/26.-Resident's family was notified of elopement on 4/23/26.-Resident's physician was notified of elopement on 4/23/26.-Elopement policy was revised to emphasize supervision and stationing staff at doorways and stairwells during fire drills. on 4/23/26.-Education on elopement policies and procedures to emphasized staff members being stationed at each unlocked exits/stairwell completed by 4/23/26.-Verified all facility staff 115 of 126 received training.-In person interviews 27 of 27 in person staff interviews confirmed receiving training with emphasis on stairwell and exit doors during fire drills.-Housekeeping contract staff verified eight of nine received education.-Therapy contract staff seven of seven staff verified received education.-Dietary contract staff 16 of 20 verified received education.-All new hires will be trained prior to the first shift on the floor.-Ad Hoc QAPI Meeting was performed discussing the event on 4/23/26.-Audits verified as complete as well as fire drills conducted, completed by 5/7/26. Interview with the Nursing Home Administrator on 6/2/26, at 3:45 p.m. confirmed that the facility failed to make certain residents receive adequate supervision for a resident resulting in an elopement from the facility on 4/22/26, at 11:29 p.m. (Resident R1). This placed all residents identified as an elopement risk at risk for Immediate Jeopardy and that the Immediate Jeopardy situation has successfully met the task of Past Noncompliance effective on 5/7/26, when the action plan was achieved by the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c) Resident Rights 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 policies, facility submitted documents, facility documentation, clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Closed Resident Record CR1) was free of neglect during care which resulted in actual harm of a fracture of their right femur (thigh bone). Findings include: Review of facility policy Recognizing Sign and Symptoms of Abuse/Neglect, dated 12/9/25, indicated all types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Sign of neglect: accidents among residents who need supervision. Review of facility policy Activities of Daily Living (ADLs), Supporting, dated 12/9/25, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:Hygiene (bathing, dressing, grooming and oral care);Mobility (transfer and ambulation, including walking);Elimination (toileting);Dining (meals and snacks); andCommunication (speech, language, and any functional communication systems). A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Closed Resident Record CR1's admission record indicated that Resident CR1 was admitted to the facility 1/8/21. Review of Resident CR1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses hemiplegia (paralysis or severe weakness affecting one side of the body, usually caused by brain or spinal cord injury), respiratory failure, and muscle wasting. Review of Section C: Cognitive Patterns indicated Resident CR1 had a BIMS score of 15, cognitively intact. Review of Section GG - Functional Abilities - Mobility, Question GG0170A indicated the resident was coded at a 01 for dependent, helper does all of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident CR1's plan of care, updated 2/25/26, revealed Bed Mobility: (Resident CR1) requires one person assist to turn and position and requires assist of two staff to pull up in bed. Review of clinical health status progress note dated 5/8/26, at 3:57 p.m., revealed witnessed fall/no injury notes at time of fall. After someone shouted that the resident (CR1) fell, found the resident (CR1) laying on the floor, on her right side, facing the window. When asked what happened, Nurse Aide (NA) Employee E6 said she (CR1) rolled off the bed while she (NA Employee E6) was changing her. Resident (CR1) said she hot her head, no bruising and hematoma noted. Resident (CR1) denies pain on her head. Resident (CR1) complained of pain on her right leg. Review of clinical physician progress note, late entry dated 5/8/26, at 11:13 p.m., indicated pain in right hip/leg: ordered x-ray (medical imaging that uses radiation to take pictures of the inside of your body). Review of clinical health status progress note dated 5/9/26, at 3:51 p.m., revealed resident (CR1) remains alert and verbally responsive, x-ray vendor came in and did stat x-ray, currently awaiting results. Review of clinical health status progress note dated 5/9/26, at 1017 p.m., revealed resident (CR1) and family has decided against hospitalization of positive x-ray that reveals right femur fracture. Review of facility provided document Radiology Results Report, dated 5/9/26, at 4:31 p.m., revealed Conclusion: there is a probable subtle supracondylar fracture (break right above the knee joint) in the distal right femur which could be acute. Review of facility submitted document PB-22 (Report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property), dated 5/14/26, indicated on 5/8/26, at 3:57 p.m., resident (CR1) received ADL care provided by NA (Employee E6). While NA (E6) was performing perineal care, she (NA Employee E6) rolled the resident (CR1) towards the window, moved away to grab a towel, and the resident (CR1) fell from bed to the floor. On 5/9/26, nurse on duty observed increased swelling and internal rotation of right lower extremity and notified medical doctor (MD). MD ordered STAT X-ray. X-ray was obtained on 5/9/26, st 3:22 p.m. X-ray results obtained and showed a probable subtle supracondylar fracture on the distal right femur. A review of the initial fall incident was conducted. It was determined that NA (Employee E6) provided care to a resident (CR1), bed elevated on an APM (alternating pressure mattress) mattress when resident slipped off and fell. Neglect was substantiated. Review of facility provided witness statement dated 5/8/26, at 4:15 p.m., provided by NA Employee E6 stated that I (NA Employee E6) was changing (CR1) as I (E6) always do I(E6) had the towels on her chair in her room as I (E6) rolled her to clean her back side and put the brief on. I (E6) walked over to grab the towels to clean her off and she (CR1) said falling by the time I (E6) went back over to adjust her she (CR1) slipped and fell on the floor. Review of facility witness statement dated 5/8/26, at 3:57 p.m., Licensed Practical Nurse (LPN) Employee E7 stated she (Employee E7) responded to emergency request that resident (CR1) rolled off bed onto floor. NA (Employee E6) said she went to get a towel and resident (CR1) rolled onto floor, citing resident (CR1) said she (CR1) was falling but NA (E6) was unable to stop fall. She (CR1) was lying prone on her back by the window on the floor. Review of facility provided witness statement dated 6/2/26, an interview conducted by the Director of Nursing (DON) of the event with NA Employee E6, revealed NA Employee E6 had Resident CR1, warmed up water, got my towels to change her (CR1) in bed. Lay her down flat, then raised her bed to my level; cleaned up area, rolled her side (right) toward the window; went over to grab the towels, she (CR1) said I'm falling. By the time NA (Employee E6) got back there, it was too late. It happened so quick. DON further questioned: Which way did you roll her? NA Employee E6 answered, I rolled her towards window. During interviews conducted with unit NA's on 6/3/26, from 12:55 p.m. through 1:25 p.m., when questioned about proper standards of care for dependent residents bed mobility, specifically when turning/positioning/rolling onto side in an elevated bed position and supervision: - NA Employee E10 responded that you always roll a resident towards you and you never leave a resident alone unsupervised especially if they have been positioned on their side. Always have supplies within reach. - NA Employee 11 responded that you never leave a resident elevated in bed, on their side, and you always roll resident towards you. - NA Employee E12 responded that you never walk away from resident during care, especially when in an elevated position on their side. Always roll resident towards yourself during care.- NA Employee E13 responded that she knew never to leave a resident unsupervised during care when in an elevated position on their side, and always roll a resident towards you.- NA Employee E14 responded that he would never leave a resident in an elevated position unsupervised. He further stated that you always roll a resident towards you during care. During an interview on 6/3/26, at 2:30 p.m., the Nursing Home Administrator (NHA) and the DON confirmed that the facility failed to ensure Resident CR1 was free from neglect when NA Employee E6 walked away during care, leaving Resident CR1 in an elevated bed position, lying on her side, resulting in a femur fracture from a fall towards the window side of her bed. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 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 policy, facility provided document, observations and staff interview, it was determined that the facility to maintain equipment in a sanitary condition for four of six meal delivery carts (Meal delivery cart 3, 4, 6, and 9)Findings include: Review of facility policy Cleaning and Sanitizing, dated 12/9/25, indicated team members maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning logs/scheduled are available for all small and large equipment. Review of facility provided document Trayline Cleaning List, indicated Task: Spray out carts; Frequency: Daily; Task: Spray out the carts; Frequency: Weekly. During multiple observations on 6/2/26, from 11:54 a.m., through 12:36 a.m., during lunch meal service, revealed the following: Meal delivery cart 3's exterior door panels and lower bumper panels were covered with old food debris and dark spots and splashes of a dark substance; top of cart had dried, old food debris, as delivered to the 3rd floor with lunch trays contained inside. Meal delivery cart 4's exterior door panels and lower bumper panels were covered with old food debris and dark spots and splashes of a dark substance; top of cart had dried, old food debris, as delivered to the 2nd floor with lunch trays contained inside. Meal delivery cart 6's exterior door panels and lower bumper panels were covered with old food debris and dark spots and splashes of a dark substance; top of cart had dried, old food debris, as delivered to the 1st floor with lunch trays contained inside. Meal delivery cart 9's exterior door panels and lower bumper panels were covered with old food debris and dark spots and splashes of a dark substance; top of cart had dried, old food debris, as delivered to the Ground floor with lunch trays contained inside. During an interview on 6/2/26, at 12:45 p.m., after Food Service Director (FSD) Employee E1 completed lunch meal service cart delivery process, FSD Employee E1 confirmed above observations of meal cart 3, 4, 6, and 9's unsanitary conditions, confirming that the facility failed to maintain equipment in a sanitary condition. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility on 4/22/26, which created an immediate jeopardy situation for all residents identified as an elopement risk.Findings include: The job description for the Nursing Home Administrator specified the duties and responsibilities of the Administrator-Skilled Nursing Facility include performing a variety of tasks associated with creating a fulfilling resident experience, including resident care coordination, teammate oversight, and regulatory reporting and compliance for the Skilled Nursing areas of the Community. Supervise all department heads to ensure the community is operating according to standards and in compliance with regulatory guidelines. The job description for the Director of Nursing specified the DON will plan, organize, develop, and direct the overall operation of the Nursing Services Department. Facilitates the coordination of nursing services and other departments to maintain quality care for residents Based on findings identified in this report, the facility failed to ensure proper supervision for a resident, resulting in Resident R1 eloping from the facility, which placed the resident in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 6/3/26, at 3:45 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent the elopement of a resident, which created an immediate jeopardy situation for all residents identified as an elopement risk. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of six residents (Residents R2 and R3).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025, indicated the following instructions:Section O0110. Special Treatments, Procedures, and ProgramsCheck all of the following treatments, procedures, and programs that were performed.K1. Hospice - mark if indicated while a resident. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section O0110 K1. Hospice - was not marked as while a resident. Review of Resident R2's physician order dated 10/18/25, indicated admit to level of care: Hospice Services. Review of Resident R2's current care plan indicated resident has a terminal prognosis related to dementia end stage and receives hospice services. Interview on 6/3/26, at 10:39 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E15 confirmed Resident R2 receives hospice services and the MDS dated [DATE], did not include hospice and it was a data entry error.Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of heart failure, high blood pressure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Section O0110 K1. Hospice - was not marked as while a resident. Review of Resident R3's physician order dated 8/20/25, indicated admit to level of care: Hospice Services. Review of Resident R3's current care plan indicated resident has a terminal prognosis related to need forhospice care. Interview on 6/3/26, at 11:15 a.m. RNAC Employee E15 confirmed Resident R3 receives hospice services and the MDS dated [DATE], did not include hospice and it was a data entry error. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).Findings include: Review of LPN Employee E7's personnel file indicated a date of hire of 8/1/24. Review of LPN Employee E7's education training records on 6/3/26, failed to include education on QAPI during the past year of employment as required. Interview on 6/3/26, at 10:30 a.m. Infection Preventionist Employee E16 confirmed that the facility failed to provide QAPI training to one of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).Findings include: Review of LPN Employee E7's personnel file indicated a date of hire of 8/1/24. Review of LPN Employee E7's education training records failed to include education on Compliance and Ethics training during the past year of employment as required. Interview on 6/3/26, at 10:30 a.m. Infection Preventionist Employee E16 confirmed that the facility failed to provide Compliance and Ethics training to one of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Behavioral training to one of five direct care facility staff reviewed (Licensed Practical Nurse (LPN) Employee E7).Findings include: Review of LPN Employee E7's personnel file indicated a date of hire of 8/1/24. Review of LPN Employee E7's education training records failed to include education on Behavioral training during the past year of employment as required. Interview on 6/3/26, at 10:30 a.m. Infection Preventionist Employee E16 confirmed that the facility failed to provide Behavioral training to one of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility policy, facility documents, staff and resident interviews it was determined that the facility failed to provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1). Findings include: Review of facility policy Answering the Call Light dated 1/2/26, indicated: The purpose of this procedure is to ensure timely responses to the residents requests and needs. General Guidelines - Be sure that the call light is plugged in and functioning at all times. Some residents may not be able to use their call light. Be sure you check these residents frequently. Review of admission Record indicated Resident R1 was admitted on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of resident needs), dated 1/24/26, indicated diagnosis of cancer( a disease of uncontrolled proliferation by transformed cells subject to evolution by natural selection), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and malignant neoplasm of larynx, unspecified ( cancer of your larynx or voice box). Section C BIMS (brief interview for mental status) indicated a summary score of 15 - cognitively intact. Review of facility documentation submitted to state agency dated 1/24/26, indicated: On 1/24/26, the resident reported that during the night shift, a nurse removed her call bell from the wall due to a technical issue but did not reconnect it afterward. The resident stated that the call bell was left on the floor and was not accessible to her. She further reported that she experienced an episode of emesis and was unable to call for assistance due to the disconnected call bell. Review of Resident R1's witness statement indicated while RN (Registered Nurse) Employee E3 was doing my feeding, the TV sound came on, and she couldn't get it to shut off. Resident asked her if she could fix it, RN Employee E3 yanked it out of the wall, left it out and stated no, I'm not a mechanic. RN Employee E3 left it like that. Review of facility documentation witness statement dated 1/26/26, RN Employee E3 indicated upon entering the resident's room while providing nursing care, resident indicated wanting the TV turned off. The monitor was off but not the sound from the remote. All procedures to cut the TV speaker off were unsuccessful. The remote was placed in the drawer, under the bedding, at the top of the bed and all were unacceptable to the resident. I apologized for the equipment failure and finished my duties. Before leaving the room, the resident wrote that if the noise was not stopped, she was going to sleep on the couch down the hall. That is what caused me to do the only thing I knew to stop the noise from the remote in her room, disconnect the remote from the wall and let it ring at the nurse's station. Review of facility documentation, witness statement dated 1/26/26, NA (Nurse Aide) Employee E2 indicated: Resident R1 put call light on I answered it she let me know that her feeding was done, and I informed RN Employee E3. I went to answer my other call lights and made sure everyone was taken care of before I went to go pump, I let the nurse know I was going to pump, and she will need to answer the call lights. When I got done pumping a couple of call lights were going off including Resident R1. RN Employee E3 told me the call light wasn't working I told her I'll take a look at it. I went in and tried to fix the light but didn't know how. Review of facility documentation witness statement undated/unsigned indicated: The call bell was going off when I came in at 2am but the room was dark and I didn't know if someone was there or not didn't see a patient at all, all night come out or the light inside the room on as if anything was wrong. I went to answer the light the nurse assigned stated the light has been broken this shift and its fine no need to go in. Review of facility documentation Team Corrective Action, dated 1/28/26, indicated: The call system has multiple functions, Nurse call, TV on/off, volume/channel selection, etc. On the day in question, it was not entirely functioning the unit was able to call nurses, turn tv remote off and on but the volume elements were inoperable. This nurse tried all elements available on the remote unit removing wall compartment several times in an attempt to restart/reboot the wall connection several times. Removing the cord was the only one that was effective in stopping the sound emanating from the unit which the resident was objecting to. At this point I apologized for the equipment failure, admitted that it was not functioning properly and there are no overnight maintenance personnel to fix it at this time. I disconnected the unit from the wall. Prior to this meeting today no policy and procedures were in place, no backup cords, no ding bells, no education and no contingency plan was in effect to address this equipment failure. Summary I did not provide Pt. with alternative call system. No alternative call system was available. Review of facility documentation to include Resident R1's MAR (medication administration record used to document medications and treatments to residents) failed to include documentation from 1:25 a.m. till 4:00 a.m. in the morning. During a phone interview on 2/11/26, at 3:06 p.m. RN Employee E3 indicated: She was the RN who took the call bell out of the wall. That the call bell was malfunctioning and she was unable to fix it. That the facility did not provide training to her prior to the re-education during the suspension on 1/28/26, that prior to that she was unaware of any hand bells, extra call bell cords etc. That she was the nurse in charge of the building, and on both carts for the third floor until later in the shift when another nurse came in around two a.m. Interview on 2/12/26, at 1:40 p.m. NHA (Nursing Home Administrator) and DON (Director of Nursing) were informed that the facility failed to provide an active and accessible call bell to Resident R1. On 2/12/26, at 1:40 p.m. NHA and DON were provided with the Immediate Jeopardy template and corrective action plan was requested. Review of the immediate action plan on 2/13/26, at 12:24 p.m. indicated: -Resident R1's call bell was tested to ensure proper functioning. Nursing staff verified that the resident had access to a functioning call system and that it was positioned appropriately to meet the resident's needs. An assessment of Resident R1 was completed to ensure no adverse outcomes occurred as a result of the one call bell being unplugged per the resident's request. Upon verification, witness statements clearly identified there was not a call bell in place until 6:30a.m. the morning of 1/25/26, and the resident was without one prior to replacement at 6:30 a.m. Assessment was completed as stated with no injuries found. -Total of 145 staff from all departments were educated. Education signatures verified 114, telephonic education 31. Nursing staff on site 14/14 verified education and understanding 4/4 housekeepers on site verified education and understanding. -All resident rooms and common areas with call bell access were inspected to assess functionality. Nursing and maintenance staff tested each call bell to ensure proper operation and accessibility. No issues with functionality were identified. Upon verification all call bells were tested and inspected for functionality, with no issues identified. An outside vendor was on site on 2/12/26, and examined the system, all activation points tested and in good working condition. -The facility conducted a root cause analysis to determine the reason for the one individual call bell functional issue; concluding user error, the bell was unplugged per the resident's request. Audit performed for the call bell system, including all resident rooms and common areas where resident may initiate a call. Verified as complete on 2/13/26. -A preventative maintenance schedule has been implemented to ensure ongoing monitoring of the call bell system. Staff were re-educated on daily visual checks of call bell accessibility and reporting procedures for any identified issues of functionality. Verified as complete on 2/13/26. -The Maintenance Director or designee will conduct three times weekly call bell functionality audits for 30 days, followed by monthly audits thereafter. Documentation of system checks will be maintained. Results will be reviewed at the Quality Assurance and performance Improvement (QAPI) meeting to ensure sustained compliance. Any deficiencies identified will be corrected immediately and reported to administration. -Verified the TELS system (an electronic tracking of maintenance concerns) had added conduct a test of the nurse call system. -Immediate corrective action for Resident R1 was completed on 1/25/26. Additionally, facility-wide call bell testing was completed on 1/26/26. Ongoing preventative maintenance and monitoring will continue as outlined above. During phone interviews on 2/13/26, employees indicated: 10:46 a.m. NA Employee E4 stated that she received several trainings recently on abuse, neglect, and what to do if the call bell stops working. Staff were taught where to find a hand bell if the call bell isn't working and the process to follow. 11:00 a.m. NA Employee E5 stated that she received several recent trainings on abuse, neglect and what to do on the hand bells. She stated she was aware the facility had them but thought only nursing could get them for residents. The training taught her where to find the call bells, and what the process is and she was previously unaware. During interviews on 2/13/26, employees indicated: 11:00 a.m. NA Employee E6 indicated even down here, (memory care unit) the resident must always have a call bell in reach even if they never use it. 11:05 a.m. NA Employee E7 indicated yes, we have ding-bells now in the nurse's station if there is a broken call bell and to never leave the resident without one. 11:10 a.m. NA Employee E8 indicated we received education and that we are to never leave the resident alone without a call bell in reach. 11:13 a.m. RN Employee E9 indicated they received training and pointed to a ding bell located behind the nurse's station that was available in the event of a broken call bell system. 11:18 a.m. NA Employee E10 indicated they received training and verbalized understanding that there are alternative methods staff can use if a call bell is broken. 11:21 a.m. NA Employee E11 indicated they received training and now have ding bells if needed. 11:28 a.m. RN Employee E12 indicated they received training and now were aware of alternative methods when a call bell breaks. 11:30 a.m. RN Employee E13 indicated they were trained and knew even before the training that you never leave a resident without a call bell. Review of immediate action plan was verified on 2/13/26, at 1:33 p.m. the Immediate Jeopardy situation was in effect from 1/24/26, through 2/13/26, when the facility completed their plan as stated. Interview with the Nursing Home Administrator on 2/13/26, at 3:00 p.m. confirmed the facility failed to provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, facility documentation, clinical record review, staff and resident interviews it was determined that the facility neglected to provide the necessary means and services for a resident to contact staff for help when the call system malfunctioned for one of two trach residents (Resident R1). Findings include: Review of facility policy Abuse, Prevention, Intervention Reporting and investigation dated 1/2/26, indicated: Residents are to be free from verbal, sexual, physical, emotional/mental abuse, self-abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion at all times. Definitions: Neglect is defined as failure to provide goods and services necessary to avoid physical harm. Mental anguish or mental illness. Review of admission Record indicated Resident R1 was admitted on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of resident needs), dated 1/24/26, indicated diagnosis of cancer( a disease of uncontrolled proliferation by transformed cells subject to evolution by natural selection), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and malignant neoplasm of larynx, unspecified ( cancer of your larynx or voice box). Section C BIMS (brief interview for mental status) indicated a summary score of 15 - cognitively intact. Review of facility documentation submitted to state agency dated 1/24/26, indicated: On 1/24/26, the resident reported that during the night shift, a nurse removed her call bell from the wall due to a technical issue but did not reconnect it afterward. The resident stated that the call bell was left on the floor and was not accessible to her. She further reported that she experienced an episode emesis and was unable to call for assistance due to the disconnected call bell. Review of facility documentation, witness statement dated 1/26/26, NA (Nurse Aide) Employee E2 indicated: Resident R1 put call light on I answered it she let me know that her feeding was done, and I informed RN (Registered Nurse) Employee E3. I went to answer my other call lights and made sure everyone was taken care of before I went to go pump, I let the nurse know I was going to pump, and she will need to answer the call lights. When I got done pumping a couple of call lights were going off including Resident R1. RN Employee E3 told me the call light wasn't working I told her I'll take a look at it. I went in and tried to fix the light but didn't know how. Review of facility documentation Team Corrective Action, dated 1/28/26, indicated: The call system has multiple functions, Nurse call, TV on/off, volume/channel selection, etc. On the day in question, it was not entirely functioning the unit was able to call nurses, turn tv remote off and on but the volume elements were inoperable. This nurse tried all elements available on the remote unit removing wall compartment several times in an attempt to restart/reboot the wall connection several times. Removing the cord was the only one that was effective in stopping the sound emanating from the unit which the resident was objecting. At this point I apologized for the equipment failure, admitted that it was not functioning properly and there is no overnight maintenance personnel to fix it at this time. I disconnected the unit from the wall. Prior to this meeting today there no policy and procedures were in place, no backup cords, no ding bells, no education and no contingency plan was in effect to address this equipment failure. Summary I did not provide Pt. with alternative call system. No alternative call system was available. Review of facility documentation indicated: Resident R1's call bell malfunctioned (tv volume was staying on). Facility staff unplugged the call bell from the wall. Left resident without a way to call for help. Facility staff neglected to provide any other way for Resident R1 to contact staff for help. Resident R1 is trach dependent and cannot speak. Resident R1 reported getting sick (emesis) and not being able to call for help. Resident R1 had to walk out to the nurse's station for help. During an interview on 2/11/26, at 1:51 p.m. Resident R1 confirmed that the call bell system was making a noise preventing her from sleeping and staff could not correct the system. That the call bell system was pulled out of the wall by RN Employee E3 and no other means of was provided to let staff know of her needs. That she threw up and to go find staff for assistance. Resident R1 indicated that staff did not come in to check on her, nor did she have a working call bell which is why she went out to find help. Interview on 2/12/26, at 1:40 p.m. NHA (Nursing Home Administrator) and DON (Director of Nursing) were informed that the facility neglected to provide the necessary means and services for a resident to contact staff for help when the call system malfunctioned for a trach dependent resident (Resident R1). 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code201.18(b)( e)(1)Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, staff and resident interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in Resident R2 being transferred to the hospital for a hematoma. This failure was determined to be past non-compliance.Findings include: Review of facility policy 1/23/26, Accidents and Incidents indicated: All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.). The circumstances surrounding the accident or incident. Where the accident or incident took place; The name of witnesses and their accounts of the accident or incident; the injured person account of the accident or incident; the disposition of the injured (i.e. transferred to hospital, put to bed, sent home, returned to work, etc.) This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. Review of admission Record indicated Resident R2 was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R2's MDS ( minimum data set - a periodic assessment of resident needs) dated 1/5/26, indicated the diagnosis of spinal stenosis (happens when the space inside the backbone is too small), other obesity due to excess calories (abnormal or excessive fat accumulation that presents a risk to health), and muscle weakness (when your muscles can't work with the expected force). Review of progress notes indicated Incident Note dated 2/8/26, Resident complained of hurting of left leg while care being performed crying currently She has tightness in her legs and had a loose stool overnight she stated no one hit her but held her legs open to clean her and now her left leg has a bruise and is painful daughter wants sent to hospital and declined Md offer to stat test for any abnormalities vs WNL (with in normal limits) resp easy 911 called for transport Md called POA (power of attorney) here and behold and medication record sent with resident. Review of hospital documentation Final Report dated 2/8/26, indicated: There is a 9 x 7 x16.6 cm. hematoma within the soft tissue plane of the left medial thigh with a small spot of active bleeding. Review of facility submitted documentation dated 2/8/26, indicated that Resident R2: requires a Hoyer lift, and it was identified that an incorrect Hoyer pad had been used.During an interview on 2/13/26, at approximately 2:45 p.m. NHA and DON were informed that the facility failed to provide adequate supervision for one resident resulting in Resident R2 being transferred to the hospital for a hematoma. NHA and DON submitted the following for Review of the facility Past non-compliance Immediate Corrective Actions F689 Mechanical (Accidents/Supervision/Assistive Devices: Hoyer Lifts & Transfers). Immediate Corrective Actions indicated the following: Resident (s) involved in the incident were assessed for injury and care needs addressed immediately.Area on Aging NotifiedFamily NotifiedPhysician NotifiedStaff suspended pending investigationResident interviews conducted by social service director to ensure resident safetyResidents were assessed by clinical staff for injury and care needs assessed.Risk Management assessment performed Clinical staff.Care plan updated to reflect Risk/Actual Skin Integrity Impairment.All resident that utilizes a Hoyer lift was assessed for injuries.The mechanical lift and sling used during the incident were inspected for safety and removed from service if defective.Staff directly involved were re-educated on proper mechanical lift operation and correct sling sizing.Systemic Changes:All nursing staff received reeducation on:Proper use of Hoyer and mechanical liftsTwo -person transfer requirements.Correct sling/pad selection based on manufacturer guidelines and resident body size.Ensuring sling compatibility with the specific lift modelSling type and appropriate size (small/medium/large/extra-large)Special considerations such as amputations, contractures, or weight distributionAll nursing staff will receive re-education on:Proper use of Hoyer and mechanical liftsTwo - person transfer requirementsCorrect sling/pad selection based on manufacturer guidelines and resident body sizeEnsuring sling compatibility with the specific lift modelSpecial considerations such as amputations, contractures, or weight distributionAudits were performed for any resident that utilizes a Hoyer lift to ensure that pad sizing is appropriate. Review of the facility Past non-compliance Immediate Corrective Actions F689 Mechanical (Accidents/Supervision/Assistive Devices: Hoyer Lifts & Transfers) was verified on 2/13/26, at 2:55 p.m. that the past noncompliance was in effect until 1/9/26, when the facility completed their plan as stated. On 2/13/26, the NHA and DON were informed that the facility failed to provide adequate supervision for one resident resulting in Resident R2 being transferred to the hospital for a hematoma.28 Pa. Code: 201.14 (a)Responsibility of licensee28 Pa. Code: 201.18 ( e)(1) Management.28 Pa. Code 207.2 (a) Administrator's responsibility.

Based on review of job descriptions, facility and clinical records, and staff interviews it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that the facility provide a fully functioning call bell system for one resident resulting in an immediate jeopardy situation for one of three residents (Resident R1).Findings include: The job description for the NHA specified that the job scope is to oversee the overall operations of the Community and is responsible for resident care, customer service, and the welfare and safety of residents. The job description for the DON specified that the job scope is to plan, organize, develop, and direct the overall operation of the Nursing services department. Facilitates the coordination of nursing services and other departments to maintain quality of care for residents. Based on the findings of this report that identified that the facility failed to provide a fully functioning call bell system for on resident resulting in an immediate jeopardy situation. The facility failed to provide fundamental principles that apply to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and facility policy.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for a Bipap device (a positive airway pressure machine when breathing in and breathing out) and failed to act on a malfunctioning Bipap in a timely manner for one of three residents (Resident R2) which resulted in actual harm of dyspnea (difficulty breathing), hypoxemia (a low level of oxygen in the blood), hypercapnia (too much carbon dioxide in the blood stream), requiring an intensive care unit (ICU - specialized hospital department where critically ill patients receive intensive, round-the-clock care) admission for Bipap. Findings include: Review of the facility policy CPAP/Bipap Support dated 1/2/25, indicated Bipap delivers continuous positive airway pressure, but allows separate pressure settings for expiration (EPAP -breathing out) and inspiration (IPAP- breathing in). Document in the resident's medical record how the resident tolerated the procedure. Review of facility provided education from April 2025, indicated Cpap vs Bipap which defined each term and compared differences in the equipment. Section titled What are the potential problems? indicated if the machine malfunctions, seek professional assistance. Review of the admission record indicated Resident R2 was admitted on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/4/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), acute and chronic respiratory failure (when the lungs can't properly exchanges gases causing abnormal levels of carbon dioxide and/or oxygen in the arteries), and heart failure (heart doesn't pump blood as well as it should). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as 15 - cognitively intact. Review of Resident R2's physician order dated 4/28/25, indicated Bipap settings (IPAP/EPAP) 18/5 with oxygen bleed at 2 liters/minute. Please fill the reservoir with sterile water. Apply Bipap at 9:00 p.m. Remove Bipap at 6:00 a.m. Review of Resident R2's care plan dated 1/7/25, indicated problem - resident is having difficulty adjusting to nursing home and is experiencing loneliness as evidenced by refusing Bipap and demanding family come in. Goal - resident will have increased compliance with Bipap use. Support calls with family as needed and assist with putting Bipap on. Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Notify physician of signs of respiratory distress. Interventions dated 9/3/24, indicated BiPap settings as ordered, and failed to identify the specific settings required. The plan of care failed to identify steps to follow in the event the machine malfunctioned or required service. Review of Resident R2's progress notes indicated the following: -Licensed Practical Nurse (LPN) Employee E6's note on 5/9/25, at 9:15 p.m. - no significant changes at this time. -Registered Nurse (RN) Employee E7's note on 5/10/25, at 3:48 p.m. - issues with the Bipap throughout the night. Evening shift nurse left note that it was not working when was placed on resident. Resident placed on 2liters of oxygen via nasal cannula (two thin prongs that sit below the nose to administer oxygen) oxygen saturation at 96 percent. Respirations at 16 breaths a minute and resident denies shortness of breath or discomfort at this time. -LPN Employee E8's note on 5/11/25, at 12:56 a.m. - no significant changes at this time. -LPN Employee E9's note on 5/13/25, at 7:04 p.m. - resident complained of shortness of breath. Oxygen water changed, inhaler given, repositioned in bed, other nurse has been in her room to fix the phone, will continue to monitor. -LPN Employee E10's note on 5/13/25, at 10:00 p.m. - at the beginning of this shift resident was complaining of shortness of breath while on the phone with the son. This nurse checked the oxygen saturation, and it was 93 percent on 2 liters of oxygen. Resident indicated their bottom hurt and legs from sitting up in the chair yesterday. This nurse offered to reposition resident, and resident said it was okay then changed their mind. Tylenol given with evening medication. Resident was changed, Bipap placed. No issues noted at this time. -LPN Employee E11's note on 5/15/25, at 2:00 a.m. from the start of shift resident constantly complaining of everything possible. Staff constantly in and out the room. Pulled up in bed numerous times vital signs taken. Oxygen saturation 99 percent on 2 liters of oxygen. Resident is calling staff saying I'm awake now and currently is screaming help calling the desk phone. When staff go in the room resident is quiet saying I'm awake, what do I do now. Resident complained of shortness of breath oxygen saturation was 99 percent, but her Bipap has not been working. Has a history where carbon dioxide rises but resident is full alert and saturations are fine at the moment. -LPN Employee E11's note on 5/15/25, at 2:14 a.m. resident ringing now, wanting to know if it's time to get out of bed. It's 2:15 a.m., redirected resident who didn't have complaints of shortness of breath at all. Saturation 99 percent. -LPN Employee E11's note on 5/15/25, at 2:57 a.m. called the On-Call doctor regarding complaints and the son. Nurse aide that is working currently said Bipap wasn't put on in the evening. The nurse stated it would just cut off. This nurse put Bipap on and water in and oxygen bleed into Bipap so far working fine. Physician stated if Bipap stops or malfunctions it's ok to send to resident to the emergency room. Resident was yelling at top of the lungs help me. Earlier in the night and became slightly sweaty. Heart rate maintained in the 80's - 90's and saturation was 99 percent. Physician also made aware of that. Son called back for update. Son is mad and on the way to the facility. -LPN Employee E11's note on 5/15/2025, at 3:08 a.m. resident's sons are here and upset about Bipap not working. They had a backup Bipap and are hooking it up right now. -LPN Employee E11's note on 5/15/25, at 3:23 a.m. the sons left secondary Bipap on and working. They apologized to this nurse and was appreciative of letting them know about resident's condition and the Bipap issues. -LPN Employee E11's note on 5/15/25, 6:01 a.m. resident responds to name answers questions still seems slightly off, such as hypercapnic like symptoms. Mentioned this to the sons when they were here about going to the hospital now. They declined and wanted to try to wear the secondary Bipap first for an extended period of time. RN Supervisor aware and physician. -RN Employee E12's note on 5/15/25, at 9:52 a.m. - resident was sent to the hospital at 9:45 a.m. Vital signs were taken. Resident was in respiratory distress. Skin diaphoretic (sweaty). Loose black stools. This writer requested to have resident go to local hospital. The paramedics took resident to a different local hospital instead, due to the resident having loose black stools. -RN Employee E4's note on 5/15/25, at 3:39 p.m. resident at hospital, the carbon dioxide is ranging from 56, 51, 44 (normal range is 35 -45). Resident will be admitted to hospital. -RN Employee E4's note on 5/15/25, at 4:51 p.m. call placed to son for update on resident. Son responded her carbon dioxide was elevated, and resident kept twitching and falling asleep intermittently. The son was also asked when here this morning at 3:00 a.m. to swap out the Bipap machine the resident uses, if the Bipap by the bedside was working upon arrival to resident's bedside. Son responded at this point I don't even know. Review of the hospital record dated 5/15/25, indicated Resident R2 with history of chronic hypercapnia (on nighttime Bipap) COPD, obstructive sleep apnea, obesity hypoventilation syndrome, who presented on 5/15/25 from skilled nursing facility due to dyspnea, hypoxemia, hypercapnia, requiring ICU admission for Bipap. Interview on 6/3/25, at 9:42 a.m. LPN Employee E11 indicated remembering a note that said the Bipap wasn't working right for Resident R2, recalled resident not being their normal self on 5/14/25, I called the resident's son to update them and asked if they knew the Bipap was broken. The son indicated not being aware. The other nurses were saying when putting the Bipap on Resident R1 in about 30 minutes it would shut off. One day the sons pulled another Bipap out and hooked that one up instead. The sons are familiar with the resident's carbon dioxide levels being elevated and didn't want Resident R2 to go to the hospital until wearing the second Bipap for a while to see if it would blow off the carbon dioxide. Later that day she had bloody stools and went to the hospital. Further indicated they've had training on the Bipap recently. Interview on 6/3/25, at 1:08 p.m. Infection Preventionist Employee E13 and Materials Manager Employee E14 indicated they checked the Bipap machine on 5/15/25, as Resident was in the hospital at this time, and it worked fine. The respiratory company checked the Bipap and indicated nothing was wrong with it. When asked how they knew which Bipap machine the vendor checked the original or secondary machine brought from family, they could not answer or provide documentation that the vendor checked the machine. Telephonic interview on 6/3/25, at 1:24 p.m. LPN Employee E8 indicated if they found the Bipap to be malfunctioning or questionable a call to the doctor and family would be made, and the respiratory company to come look at the machine. Telephonic interview on 6/3/25, at 1:47 p.m. RN Employee E7 indicated being familiar with Resident R2 and that the Bipap was not liked by Resident R2. Indicated upon arrival to Resident R2's room the tube that connects to the mask and to the machine itself whenever in the room the tube would be off, and they would reconnect it. The only issue with the Bipap for RN Employee E7 was with the tubing. Further indicated they've had training on the Bipap recently. Interview on 6/3/25, at 1:52 p.m. LPN Employee E6 indicated Everyone says it's not broke, but sometimes you'll turn it on, and it turns itself back off. You try to put it back on and it stops blowing and turns off again. This happens once in a while not all the time. The day I left the note I turned the Bipap on, and I stood there to make sure the numbers were right, and the air was blowing, it didn't blow, and it shut itself off, and kept shutting off after I turned it back on. I told the next shift to keep a good eye on it. When asked if the physician or family was notified, LPN Employee E6 indicated No, I'm sorry, I did not. Interview on 6/3/25, at 2:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain the facility failed to follow a physician order for a Bipap device, failed to act on a malfunctioning Bipap in a timely manner which resulted in actual harm of dyspnea, hypoxemia, hypercapnia, and requiring intensive care unit admission for Bipap. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (fracture of fibula-lower leg) for one of two residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse Neglect Exploitation General Policy dated January 2022 indicated the facility will provide a safe environment where residents are protected from all forms of abuse to include neglect. Residents must not be subjected to abuse/neglect by anyone including facility staff. Through elements of screening, training, prevention, identification, investigation, protection, and reporting, the facility will act to prevent abuse. A review of the facility policy Safety-Lift dated January 2022 indicated mechanical lifts will be used for residents who cannot be transferred comfortably and/or safely by normal transfer techniques. Two staff members must always be present to perform lifts with a Hoyer lift (mechanical lift used to transfer residents). A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes and end stage kidney disease. A review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 8/15/22, indicated that the diagnoses remained current. Resident R1 is alert and oriented and able to make needs known. A review of Resident R1's care plan dated 7/18/22, indicated that Resident R1 was at risk of falls due to weakness and deconditioning, and impaired safety awareness. Facility staff would provide Resident R1 with appropriate assistive devices for safe transfers. The care plan stated that the resident required a mechanical lift with assist of two for transfers. A review of Resident R1's Kardex (document that provides resident level of assistance for nursing staff) dated 8/29/22, indicated that the resident was a transfer assist of two staff with a Hoyer lift. A review of Resident R1's physician orders summary dated 9/1/22, indicated that Resident R1 was to be transferred with a Hoyer lift. A review of an incident report dated 9/12/22, indicated Resident R1 complained of left lower extremity pain after transfer from the shower chair to the bed. The CRNP (Certified Registered Nurse Practitioner) was notified and examined the resident and the resident was transferred to the hospital for evaluation. A review of a hospital X-ray report dated 9/12/22, indicated a fracture of the left fibula. A review of NA (Nursing Aide) Employee E1 Witness Statement dated 9/12/22, indicated that the Nurse Aide moved Resident R1 from the shower chair to the bed by myself and the resident had some discomfort. A review of NA Employee E1's employee transcript dated 11/6/19, indicated he had received education on proper body mechanics, and abuse/neglect annually and last updated 11/15/22. During an interview on 11/17/22, at 2:00 p.m. the Director of Nursing (DON) confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 as they did not use a mechanical lift as ordered to transfer Resident R1. During an interview on 11/17/22, at 1:20 p.m. NA Employee E1 stated he transferred Resident R1 without a mechanical lift because he felt he was strong enough to lift her into bed. He stated he knew Resident R1 was a transfer with a Hoyer lift, but he did not follow the Kardex. During an interview on 11/17/22, at 12:45 p.m. Resident R1 confirmed that on 9/12/22, Employee E1 transferred her from the shower chair to the bed by lifting her out of the chair. Resident R1 stated I stood and had excruciating pain in my left leg. During an interview on 11/17/22, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that Resident R1 was free from neglect by not providing the necessary services, which resulted in Resident R1 suffering physical harm from a fractured left fibula. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.

Based on review of facility documentation, review of manufacturer guidelines and staff interviews, it was determined that the facility failed to utilize equipment and provide care to prevent accidents, resulting in actual harm to one of five residents reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 5/9/16, indicated that Resident R1 had severely impaired cognitive skills, required extensive assistance of one person for bed mobility and extensive assistance of two for transfers. Resident R1's May 2016, care plan indicated that Resident R1 was at risk for falls and required a full body mechanical lift (assistive device used to transfer patients from bed or chair using hydraulic power) with the assistance of two people. The manufacturer guidelines for the, Liko Viking Mobile Lift (a mechanical lift) indicated to select the lift accessory (sling - used for residents with limited mobility, supports the resident during the lift) in terms of type, size, and design and to attach the accessory correctly and safely in order to prevent injuries. The manufacturer guideline for the OctoStretch sling indicated it was designed for transferring residents in a horizontal (laying down) position. The manufacturer guideline for the high back sling indicated it was designed to provide whole body support for transfers into a reclined seated posture. Review of the information dated 6/3/16, submitted by the facility indicated that Nurse Aides (NA), Employee E1 and Employee E2, were transferring Resident R1 out of bed to a seated position via a mechanical lift. Resident R1 fell backwards onto the floor and obtained a laceration (open wound) to the head. The facility investigation determined that Employees E1 and E2 utilized a sling that is designed to transfer persons in a horizontal position (the OctoStrech sling) and not the high back sling that is to be used for whole body lifting support to a seated position. Resident R1 was transferred to the hospital on [DATE], where a three centimeter occipital (head) laceration was closed with staples (metal surgical skin closures). A follow-up X-ray which was ordered on [DATE], revealed a left hip fracture. Resident R1 was transferred to Hospice care (care that focuses on the chronically or terminally ill) on 6/9/16, with a [DIAGNOSES REDACTED]. Resident R1 ceased to breathe on 6/10/16. During an interview on 6/22/16 at 1:00 p.m., the Nursing Home Adminstrator and the Director Nursing confirmed that the facility failed to utilize equipment properly during a transfer, resulting in actual harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/26/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/26/16, 3/26/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/24/16, 2/26/16, 3/26/15.