Every finding on record at Caring Heart Rehabilitation and Nursing Center

Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to provide meals that were palatable for taste and temperature for two of six residents interviewed (Resident R1 and R2). Findings Include: Interview on August 26, 2026, with Resident R1 the resident reported that food served by the facility is cold. Interview on August 26, 2026, with Resident R2 the resident reported that food served by the facility is cold. Review of the facility's Test Tray - Meal Audit Form, dated August 26, 2026, revealed the facility's established temperature standard for hot food was 120 F or greater. On August 26, 2026, a test tray was conducted during the lunch meal service on the 4th Floor Nursing Unit. The test tray left the kitchen at approximately 12:30 PM, arrived on the unit at approximately 12:34 PM, and the passing of meal trays was completed at approximately 12:38 PM. On August 26, 2026, Food Service Director, Employee E3, obtained temperatures of the food items on the test tray revealing the following temperatures:Baked ham - 99 Fahrenheit (F)Roasted potatoes - 98 FCabbage - 100 FFruited gelatin - 50 FCoffee - 150 FCranberry juice - 45 F The test tray confirmed the baked ham, roasted potatoes, and cabbage measured below the facility's established temperature standard for hot food. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observation and interviews with staff and residents, it was determined that the facility did not ensure an effective pest control program on one of three nursing floors (4th Floor Cliveden Unit) .Findings Include: Clinical record review revealed Resident R202 was initially admitted to facility on October 14, 2020 with diagnoses of Cerebrovascular Disease (types of conditions that affect blood flow and blood vessels in the brain), cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (condition causing paralysis or weakness of/inability to move one side of the body, resulting from a stroke), and unspecified skin changes. Further review of clinical records revealed resident has a diabetic ulcer of her right heel and Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer of the sacrum. Continued review of the resident's clinical record revealed that the resident was fully incontinent of bowel (fecal incontinence). Observation on May 28, 2026, at 12:00 PM revealed three flies circling the bed of Resident R202, who resided on the 4th Floor Cliveden Unit. Interview with Resident R202's Licensed Nurse, Employee E12, on May 28, 2026, at approximately 12:05 PM revealed resident has had a persistent diarrhea issue recently, requiring staff to redress her sacral wound approximately 4-5 times a day, stating it was hard to keep the flies away. Interview with Licensed Nurse, Employee E12 confirmed observation of the flies at the time of interview. 28 Pa. Code 201.18 (1)(3)(2.1) Management

Based on observation, review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that a comprehensive care plan was developed in a timely manner related to dentures, vision needs, and dialysis for three out of 35 residents reviewed (residents R13, R23, and R48). Findings Include: Review of clinical records revealed Resident R13 was initially admitted on [DATE] with diagnoses including but not limited to history of cerebral infarction (stroke), dysphagia- oropharyngeal phase (difficulty moving food/liquid from the mouth through the throat and esophagus), and protein-calorie malnutrition (serious or potentially life-threatening condition resulting from insufficient intake of protein, calories or both). Interview with Resident R13 on May 27, 2026 at 10:55 AM revealed he has top and bottom dentures and the bottom denture was broken in half (top denture was intact), so he has not been wearing them, but stated he really needs them to chew. He further stated he has a few scattered natural teeth on his bottom jaw. Interview with Resident R13's Licensed Nurse, Employee E12, on May 27, 2026 at 10:59 AM, revealed she was aware of the broken denture and had notified Administration about it, and believed the matter of replacing it was an insurance issue. She further stated Resident R13 had been downgraded to a mechanical soft diet in the meantime and would communicate what she could find out from Administration. Further interview with Licensed Nurse Employee E12 on May 28, 2026 at 1:05 PM revealed she had brought the matter of Resident R13's broken denture to her Unit Manager's attention and confirmed they were told it was an insurance issue and would need to go through Administration. Interview with Director of Nursing, Employee E2 on May 28, 2026 at 2:30 PM revealed Administration was aware of Resident R13's broken denture and need for a replacement bottom denture and was working on it, as only the bottom denture was broken. She stated this happened when Resident R13 moved rooms within the facility, and as a result, Administration would have to pay for the denture replacement. Review of Resident R13's clinical record revealed Resident R13 had a room change to room [ROOM NUMBER]A on April 23, 2026, so this was approximately one month ago. Review of Resident R13's clinical records revealed no care plan was developed related to resident's need for dentures, although there was mentioned the need for a mechanically altered/therapeutic diet, initiated on January 23, 2026 and revised on May 26, 2026. Review of Resident's Minimum Data Set (MDS) Quarterly Assessment, dated April 30, 2026 revealed for section L0200 (Dental) incorrect answers No to both questions Broken or loosely fitting full or partial denture (chipped, uncleanable, or loose)? and Mouth or facial pain, discomfort or difficulty with chewing? Interview with the MDS Coordinator, Employee E15, on May 29, 2026 at 11:23 AM revealed she obtains her information for the MDS Assessments from the Annual or admission Assessments; she stated the Annual assessment listed Resident R13 as edentulous (missing all natural teeth of the upper, lower, or both jaws). Interview with Director of Nursing, Employee E2 on May 29, 2026 at 11:15 AM confirmed there was no Care Plan in place related to dentures for Resident R13. Review of Resident R48's clinical record revealed that resident R48 was admitted to the facility on [DATE], and had diagnoses including, but not limited to, end-stage renal failure, kidney transplant failure, and dependence on renal dialysis. A comprehensive care plan was initiated for the resident on January 31, and the initial comprehensive MDS (Minimum Data Set- a periodic assessment of resident care needs) was completed on February 9, 2026. The MDS assessment noted in section O, Special Treatments, that the resident was receiving hemodialysis. Review of the resident's care plan revealed that a plan was not developed for his dialysis treatment until March 17, 2026. During an interview with employee E2, the Director of Nursing on May 29, 2026, at 11:15 a.m., she confirmed that the comprehensive care plan for resident R48's dialysis was not developed in a timely manner. A review of the clinical record for Resident R23 on May 28, 2026, revealed Resident R23 was admitted [DATE], with diagnoses that include Muscle Weakness (Generalized) (overall muscle weakness, Primary Open-Angle Glaucoma, Bilateral, Stage Unspecified (increased eye pressure) and Major Depressive Disorder (persistent sad feeling). Review of the resident's current comprehensive care plan revealed the facility failed to identify goals, approaches, or interventions addressing the resident's visual impairment, glaucoma, vision monitoring, safety risks associated with impaired vision, or adaptive devices utilized by the resident. Observation conducted on May 28, 2026, in Resident R23's room revealed a large magnifying glass on the resident's dresser. During an interview, on May 28, 2026, Resident R23 stated that his daughter purchased the magnifying glass to help him see better. Resident R23 further stated he was aware of his vision impairment and that his daughter assisted him with vision-related needs. During an interview on May 28, 2026, Director of Nursing (DON) E2 acknowledged awareness of Resident R23's diagnosis of glaucoma. E2 was unable to provide evidence that the interdisciplinary team had incorporated the resident's visual impairment and glaucoma into the comprehensive care plan. E2 confirmed there was no care plan addressing Resident R23's visual impairment and stated that one should have been in place. 28 Pa. Code 211.11 – Resident care plan

Based on observation, review of clinical record and interview with resident and staff, it was determined that the facility did not ensure that clinical documentations were accurate for two of 35 residents reviewed. (Residents R158 and R257) Findings include: Review of Resident R257's clinical record revealed that Resident R257 was admitted to the facility on [DATE], with diagnoses of but not limited to Diabetes Miletus and Chronic Kidney Disease. Review of admission assessment dated [DATE], revealed that assessment identified resident as having teeth. Observation on Resident R257 conducted on May 27, 2026, at 10:34AM revealed that Resident was did not have teeth. Interview with resident R257 conducted at the time of the observation confirmed that he did not have any natural teeth. Further Resident R257 revealed that he left his dentures in his house. Interview with DON (director of Nursing) Employee E2 conducted on May 29, 2026, at 8:38AM confirmed that Resident R257 did not have any teeth. Employee E2 also confirmed that Resident R257's admission assessment dated [DATE], was inaccurate. Review of records for resident R158 revealed that he was admitted to the facility on [DATE], and had diagnoses including, but not limited to, obstructive and reflux uropathy (obstructive uropathy is a blockage in the urinary tract that prevents normal urine flow, reflux uropathy is when urine flows backward from the bladder toward the kidneys; both conditions can cause permanent kidney damage), and benign prostatic hyperplasia (an enlarged prostate not cause by cancer, which may contribute to urinary tract abnormalities).Observation of the resident on May 26, 2026, at 10:30 a.m. revealed that he had a foley catheter (a tube inserted through the urethra into the blader in order to empty it of urine). Review of the resident's physician orders revealed an order for indwelling catheter (foley) dated April 6, 2026. This order did not specify the size of the catheter used. Interview with employee E2, the Director of Nursing, on May 29, 2026, at 11:15 a.m. confirmed that orders for foley catheters are expected to include the size of the catheter used and confirmed that resident R158's catheter order was not complete. 28. Pa. Code211.5 Medical records

Based on observation, review of clinical record, staff interviews and review of facility policy, it was determined that the facility failed to ensure that residents were free from medication errors related to crushed medications for one of 42 residents observed. (Resident R98).Review of facility policy on medication administration with a most recent revision date of November 2025, revealed that under section POLICY: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Under section GUIDELINES: #11 Administer medication as ordered in accordance with a manufacturer specification. #c. Crush medications as ordered. Do not crush medications with do not crush instructions. Review of Resident R98's clinical record revealed that Resident R98 was admitted to the facility on [DATE], with diagnoses of but not limited to Heart Failure and Hypertension (high blood pressure). Further review of Resident R98's clinical record revealed an order for Isosorbide Mononitrate ER (Extended Release0 Oral Tablet 24 Hour 120 MG (milligrams) give 1 tablet by mouth one time a day for htn (hypertension) with an order date of April 1, 2026, and NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine) Give 1 tablet by mouth one time a day for htn with an order date of April 29, 2026. Medication administration observation on Resident R98 conducted on May 28, 2026, at 9:25AM, revealed that licensed nurse, Employee E16 crushed all of Resident R98's medication. Interview with Employee E16 conducted during the observation revealed that Resident R98 prefers to have his/her medications crushed and taken with apple sauce. Further interview with Employee E16 confirmed that there was no order to crush Resident R98's medications. Further Employee E16 also confirmed that he/she crushed the Isosorbide ER (extended release) 120 mg and Nifedipine ER 60 mg. Interview with DON (director of nursing) Employee E2 and Medical Director Employee E17 conducted on May 29, 2026, at 2:45PM confirmed that the Isosorbide ER (extended release) 120 mg and Nifedipine ER 60 mg. should not have been crushed. 28 Pa. Code 211.9 Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, record review, and interviews with staff, it was determined that facility did not ensure that care plan was updated in a timely manner to reflect current care needs related to urinary catheter use for one of 35 residents reviewed (R158) Findings include:Review of records for resident R158 revealed that he was admitted to the facility on [DATE], and had diagnoses including, but not limited to, obstructive and reflux uropathy (obstructive uropathy is a blockage in the urinary tract that prevents normal urine flow, reflux uropathy is when urine flows backward from the bladder toward the kidneys; both conditions can cause permanent kidney damage), and benign prostatic hyperplasia (an enlarged prostate not cause by cancer, which may contribute to urinary tract abnormalities).Observation of the resident on May 26, 2026, at 10:30 a.m. revealed that he had a foley catheter (a tube inserted through the urethra into the blader in order to empty it of urine). Review of the resident's physician orders revealed an order for indwelling catheter (foley) dated April 6, 2026. Review of the resident's care plan revealed a plan for bladder incontinence dated April 3, 2026. An incomplete plan was developed for his foley catheter on May 19, 2026, consisting only of a focus which stated, The resident has (SPECIFY: Condom/Intermittent/Indwelling/Suprapubic) Catheter: Neurogenic bladder. This focus was not specific, and had no associated measurable goals or interventions developed. Interview with employee E2, the Director of Nursing, on May 29, 2026, at 11:15 a.m. confirmed that the resident's care plan was not updated timely and thoroughly to reflect a change in urinary status. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, review of facility policy and interview with staff, it was determined that facility did not ensure drugs and biologicals were stored according to professional standards for 2 of 6 medication rooms observed. Findings include:Review facility policy on Medication Storage with a most recent revision date of November 2025, revealed that under section POLICY: It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication carts or medication rooms according to the manufacturer's recommendations to ensure proper sanitation temperature, light, ventilation, moisture control, segregation and security. Under section GUIDELINES: #1. General Guidelines: #a. All drugs and biologicals will be stored in locked compartments under proper temperature controls. #b. Only authorized personnel will have access to the keys to locked compartments. #2. Narcotics and Controlled Substances: #a. Schedule two drugs and backup stock of schedule 3, 4 and 5 medications are stored under double lock and key. #b. Schedule two controlled medications are to be stored within a separately locked, permanently affixed compartment when other medications or stored in the same area. Review resident R178's clinical record revealed that Resident R178 was admitted to the facility on [DATE], with diagnosis of Epilepsy (brain condition that causes recurring seizures) and Protein-Calorie Malnutrition. Review of Resident R178's physician orders revealed an order for the following: Dronabinol Oral Capsule 2.5 MG (milligrams) Give 2.5 capsule by mouth three times a day for pain -Start Date-05/03/2026-Discontinue Date-05/04/2026, Diazepam 10mg suppository insert 1 suppository rectally every 15 minutes as needed for active seizures maximum of 3 dose per episodes-Start Date-04/24/2026, and Lorazepam Oral Concentrate 1 MG/0.5ML give 1 mg by mouth every 4 hours as needed for anxiety for 14 Days 1mg (0.5ml)-Start Date-04/21/2026. Observation of the 5th floor Cliveden Unit medication room conducted on May 26, 2026, at 10:05 a.m. with Unit manager Employee E8 revealed that the medication refrigerator was not locked. Further, the narcotic box inside the refrigerator was unlocked. Further observation revealed nine capsules of Dronabinol 2.5 mg labelled with Resident R178's name, was in the refrigerator outside of the narcotic bin. Further, one open vial of Lorazepam oral concentrate 2mg/ml containing 29.5 ml of liquid, labelled with Resident R178 was in the unlocked narcotic box. Further, six Diazepam -10 mg suppositories labelled with Resident R178's name was also in the unlocked narcotic box. Interview with Unit manager, Employee E8 conducted at the time of the observation confirmed that the nine capsules of Dronabinol 2.5 mg labelled with Resident R178's name was in the refrigerator outside of the narcotic bin. Further, Unit manager Employee E8 also confirmed that one vial of Lorazepam oral concentrate 2mg/ml opened containing 29.5 ml of liquid, labelled with Resident R178's name and six Diazepam -10 mg suppositories labelled with Resident R178's name were in the unlocked narcotic box. Observation of the 5th floor Mt. Airy medication room refrigerator conducted on May 26, 2026, at 10:30AM with Unit manager Employee E8 revealed one open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml. Further observation revealed that the open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml did not have a date opened affixed to it. Interview with Employee E8 confirmed that an open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml did not have a date opened affixed to it. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. 211.12(c)(d)(1) Nursing services

Based on observation, review of clinical records and facility policy, and staff and resident interviews, it was determined that the facility did not ensure food preferences were honored for one of one residents reviewed (Resident R57).Findings Include: Clinical record review revealed Resident R57 was admitted to the facility April 10, 2026 with diagnoses of mononeuropathy of bilateral lower limbs (condition caused by damage/dysfunction of a single peripheral nerve, or bundle of nerve fibers branching off from the brain or spinal cord that connects with other parts of the body; having condition in both legs, in this instance), acquired absence of other specified parts of digestive tract (having part of digestive tract removed), malignant neoplasm of colon (colon cancer) and adult failure to thrive (disorder characterized by physical, cognitive and functional decline). Review of Resident R57's MDS (Minimum Data Set - a federally required resident assessment completed at a specific interval) assessment, dated April 16, 2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of Resident R57's dietary orders, dated April 10, 2026, and edited April 24, 2026, revealed a regular diet, regular texture, thin liquids consistency diet, with further instructions for large portions to be given for all meals. Review of Resident R57's clinical records indicate on the face sheet food allergies to gluten, milk and wheat. Review of Resident R57's care plan, initiated on April 27, 2026, revealed goal statement of her decision not to eat gluten/wheat and dairy, with intervention including same: Resident has chosen to avoid dairy/wheat and gluten. Review of Resident R57's Nutrition Assessment, dated April 24. 2026 revealed, that the Registered Dietician spoke with the resident's daughter who reported that the resident doesn't have an actual diagnosis of these allergies. The resident's daughter communicated that the resident read a book and is following a diet that recommends not eating dairy, wheat/gluten. Dislikes including wheat, dairy and gluten entered into food service portal and communicated to kitchen to offer alternatives. Interview with Resident R57 on May 27, 2026, at 12:25 PM revealed she is allergic to wheat and milk, so she cannot have bread and pasta (contain flour) and milk, so no pudding, ice cream or yogurt, but she can have butter and cream. She stated she cannot have milk, not all dairy, and only milk contains lactose, which most of kitchen staff do not seem to understand and also stated someone from the kitchen made a comment that showed they did not know wheat was in a cookie. She, additionally, stated she has received cream of wheat on at least one occasion. Further interview with Resident R57 revealed she is given chicken all the time, sometimes twice in the same day (for lunch and dinner meals), and that the kitchen does not give her beef often, and she is not sure why. She stated she would like beef, potatoes, spinach, and white rice less often than she currently receives. Additionally, Resident R57 stated she had asked to speak to the Dietician but that they have not come in, and assumed that really only the dietician and chef understand her diet but likely not most of the general kitchen staff. Continued interview with Resident R57 revealed the Always Available Menu is not always available, and stated she was unable when she has called down to the kitchen to get food on this menu outside of a mealtime. Observation of Resident R57's lunch being served on May 27, 2026 at 12:25 PM revealed resident was served apple crisp for dessert, which nurse aide who brought in the lunch tray, Employee E11, quickly took away, with Resident R57 commenting Yeah, I don't want that and can't have that, but they served it to me anyway. Observation of lunch meal ticket revealed printed statement no substitute for apple crisp on the ticket. Interview with Registered Dietician/Regional Dietary Consultant, Employee E7, on May 28, 2026 at 11:07 AM revealed resident has no actual diagnosis of allergies to gluten, milk and wheat, and that it is resident's preference not to eat these foods. Employee E7 further stated resident is malnourished according to her Dietary Assessment, and is prescribed large (1.5 times) portions with meals, partly due to the fact that Resident R57 has refused supplements (such as Ensure). Further interview with Employee E7 revealed preferences drive the bus meaning the dietary department always tries to honor residents' preferences if possible, and also that the Menus can be personalized. 28 Pa. Code 211.6(a)Dietary services 28 Pa. Cide 201.18(b)(1) Management

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, in accordance with professional standards for food service safety.Findings include: A tour of the Food Service Department was conducted on May 26, 2026, at 10:05 a.m. with Employee E6, Food Service Director (FSD), revealed the following concerns: The hallway leading from the receiving to the kitchen is lined with three old mattresses, two wheelchairs, a 5-gallon pail of dish room chemical with lid open and a heavy build-up of dirt and debris including splintered wood and paper on the floor. Observations in the walk-in cooler revealed a build up of black substance on the walls. Observations in the tray-line area revealed a build up of dust and dirt on the under shelves of the steam tables and a peeling off of a vinyl like covering revealing rust colored stains on the metal. Observations in the kitchen area revealed the baseboard tiles were loose and pulled away from the walls with some lying on the floor outside the walk-in cooler. Observations in the dish room area revealed broken floor tiles and missing grout around the drain and surrounding area. Observations in the pot sink area revealed dirt splashed on the walls. Observation in the reach-in refrigerator in the cooks area revealed dirty door gaskets. Observations in the kitchen area revealed a three-door reach in refrigerator that was out of order, but had no signage alerting staff not to use it. Interview with the Food Service Director, Employee E6 on May 26, 2026, at 10:25 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area.Findings include: A tour of the Food Service Department was conducted on May 26, 2026, at 10:05 a.m. with Employee E6, Food Service Director (FSD), revealed the following concerns: Observations in the receiving area revealed at least three bags of trash stuck under the dumpster/compactor. There were 17 broken wooden pallets leaning against the wall of the building with boards with nails facing up laying on the ground, and two wooden doors leaning against the wall. Interview with the FSD on May 26, 2026, at 10:25 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to access to hand sanitizer and personal protective equipment (PPE) on two of ten nursing units reviewed (Cliveden Second Floor A and B Wings). Findings Include: Observation on May 27, 2026, at 8:55 a.m. on the second floor (Cliveden), Licensed Practical Nurse (LPN) E20 was observed administering medications to Resident R60, who was on Enhanced Barrier Precautions, and subsequently to Resident R193, who resided in the same room, without performing hand hygiene upon entering or exiting the resident room or between resident contacts during medication administration. Further observation revealed no hand sanitizer dispensers were available along the hallway on the second floor (Cliveden) Interview on May 27, 2026, at 8:58 a.m., LPN E20 confirmed that hand hygiene was not performed during medication administration to Resident R60 and Resident R193 Record review on May 27, 2026, revealed facility policy on infection prevention and control indicated that staff are required to perform hand hygiene before and after each resident interaction and before performing clean or aseptic tasks, including medication administration. Observation on May 28, 2026 at 1:35 PM on the 5th Floor Cliveden Unit, revealed signs for room [ROOM NUMBER] stating Enhanced Barrier Precautions and Contact Precautions. Further observation in front of room [ROOM NUMBER] revealed two bins labeled used washable gowns only and trash only in the hallway to the right of the entry door outside the room. Clinical record review for Resident in room [ROOM NUMBER]-A, Resident R283 revealed an order for contact isolation, dated May 21, 2026, was in place related to her having an infection with c. difficile. Interviews with Nurse Educator/Infection Preventionist, Employee E14 and Unit Manager for 5th Floor/Mt. Airy and Cliveden, Employee E8 on May 28, 2026 at 1:38 PM revealed staff had been using reusable gowns last night and likely pushed the bins out of the way (and into the hallway) so that the resident, who has a larger body habitus, could get through the doorway to her bedroom, room [ROOM NUMBER], in her wheelchair. Employee E14 further made a phone call and then stated, They said they are taking both bins downstairs, and confirmed the bins should not be outside of the room in the hallway, as doffing (removal of soiled Personal Protective Equipment) should take place inside the room before exiting the room. Observations on Cliveden second floor on May 27, 2026, at 11:35 a.m. revealed eleven rooms on A wing with enhanced barrier precautions signs posted on the doorways and there was no hand sanitizer dispensers in the entire hallway and only one bin of PPE which included about 15 disposable gowns and one open box of large gloves. Interview with Employee E4, LPN, confirmed that there was no hand sanitizer on the hall, she checked her cart and there was no hand sanitizer on her cart, and she said that she uses her personal pocket size hand sanitizer. She also confirmed that there is only one bin of PPE on this hallway. Interview with Employee E3, Unit Manager, on May 27, 2026, at 11:55 a.m. confirmed the above findings and also that the B wing on second floor Cliveden had seven rooms on enhanced barrier precautions and there was only one hand sanitizer across from the nurses station, which is not near the resident rooms, and there was only one bin of PPE which had about 20 gowns and one open box of gloves for staff to use to care for the residents on this hallway. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)5 Nursing services

Based on review of records, observation of the resident, and interview with staff, it was determined that the facility did not ensure that MDS assessment was accurately completed related to physical restraints for one of 35 records reviewed (resident R5). Findings include:Review of resident records revealed that resident R5 was most recently admitted to the facility on [DATE], and had diagnoses including, but not limited to, acute respiratory failure, generalized muscle weakness, type 2 diabetes, anxiety and depression. Review of the resident's MDS (Minimum Data Set- a periodic assessment of resident care needs) dated March 6, 2026, section P, Restraints and Alarms, revealed that he was coded as using trunk restraints less than daily while in bed. Observation of the resident while in bed on May 26, 2026, at 10:45 a.m. revealed that he was not utilizing any restraints. Review of the resident's physician orders, care plan, and assessments revealed no mention of any type of restraint.In an interview on May 28, 2026, at 10:47 a.m., employee E2, the Director of Nursing, stated that the resident did not use any restraints. In an interview with employee E15, the MDS coordinator, on May 28, 2026, at 11:10 a.m., she confirmed that resident R5 had not been utilizing restraints of any kind, and that the MDS was coded in error. 28 Pa. Code 201.14(a) Responsibility of licensee55 Pa. Code 1187.22(5) Ongoing responsibilities of nursing facilities

Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that medication administration records were completed for two of seven residents. (Residents Cl1 and Cl2). Findings include:A review of the policy titled medication administration dated November 28, 2016, revealed that it was the responsibility of the licensed nursing staff to administer medications in accordance with professional standards of practice and as ordered by the physician. The policy also indicated that the medication was to be administered as ordered by the physician and in accordance with manufacturers' specifications. The nurse was to observe the resident consume the medication. The medication was to be recorded onto the medication administration record, which was part of the resident's clinical record. A review of the policy titled medical record documentation dated November 2025, revealed that each resident's medical record was to contain an accurate representation of the resident through complete, accurate and timely documentation. The policy indicated that licensed staff and the interdisciplinary team members were to document all assessments, observations and services provided for each resident in the medical record in accordance with state law and the facility policy. The policy said that documentation shall be factual, accurate, relevant and complete containing sufficient details about the resident's care and/or responses to care. Clinical record review for Residents Cl1 and Cl2 revealed that the nursing staff failed to completely and accurately document that medications and treatments were administered as ordered by the physician.Clinical record review for Resident Cl1 revealed that this resident had diagnoses of asthma, hypertension, depression, hypoxia, diabetes mellitus and severe stenosis with myelomalacia. The physician had ordered formoterol fumarate inhalation nebulizer solution 20MCG/2ml inhale orally via nebulizer two times a day for asthma. The licensed nurse documented on November 2, 2025, that the 5:00 p.m., dose of inhalation medication for asthma was not administered to Resident Cl1. A licensed nurse documented on November 4 and November 9, 2025, that the 5:00 p.m., doses of medication for formoterol fumarate inhalation nebulizer solution 20MCG/2ml inhale orally via nebulizer were not administered to Resident Cl1. The physician had ordered pregabalin oral capsule 25 mg be administered twice a day for cerebral vascular accident for Resident Cl1. A licensed nurse documented that on November 4, 9 and 10, 2025 the 5:00 p.m., doses of pregabalin oral capsule 25 mg were not administered to Resident CL1 for the diagnosis of cerebral vascular accident. A licensed nurse documented that on December 10, 2025, and December 11, 2025, the 9:00 a.m., the doses of pregabalin oral capsule 25 mg were omitted for Resident Cl1 for the treatment and diagnosis of cerebral vascular accident. The physician had ordered insulin lispro injection three times a day for a diagnosis of diabetes mellitus with a sliding scale amount of insulin, after a blood glucose reading was taken and recorded by the nurse for Resident Cl1. A licensed nurse documented at 5:00 p.m., on November 4 and 9, 2025 that blood glucose was not taken or recorded for Resident Cl1 and that insulin for diabetes mellitus was not administered as ordered by the physician for Resident Cl1. The physician ordered topical gel 1% to be applied for bilateral knee pain for Resident Cl1. On November 4 and November 9, 2025, the 5:00 p.m., doses of topical cream were not applied to the bilateral knees for pain for Resident Cl1 as ordered by the physician. Clinical record review for Resident Cl2 revealed that this resident had diagnoses of anxiety disorder, end stage renal disease, sepsis and spina bifida. Clinical record review for Resident Cl2 revealed that the physician had ordered Ativan (an antianxiety agent) orally 2mg 1 tablet by mouth every 12 hours for anxiety. The licensed nurse documented on December 11, 2025, that the medication Ativan was administered to Resident Cl2 at 9:00 a.m., and 9:30 p.m., as ordered by the physician. A licensed nursing staff member documented that at 9:30 p.m., on December 12, 2025, the 2mg dose of Ativan was omitted for Resident Cl2. A licensed nurse documented that the 2mg dose of Ativan was not administered to Resident Cl2 at 9:00 a.m., on December 13, 2025, as ordered by the physician. A licensed nurse documented that on December 16, 2025, the 9:30 p.m., dose of 2mg of Ativan was not administered to Resident Cl2 as ordered by the physician. A licensed nurse documented on December 18, 2025, that the 2mg dose of Ativan was not administered to resident Cl2 as prescribed by the physician. Interview with the assistant director of nursing, Employee E2, at 10:00 a.m., on December 30, 2025, confirmed the lack of medical record documentation to indicate that Residents Cl1 and Cl2 received medications and treatments according to professional standards of nursing practice for medication administration and required medical record documentation. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(3)(5) Nursing services28 PA. Code 211.5(f)(i)(ii)(iii)(vii)(viii)(ix)(x) Medical records

Based on observations, clinical record review, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences timely to ensure updates for four of twelve residents reviewed. (Residents R4, R5, R6, R7)Findings Include: During the entrance conference held on November 25, 2025 at 9:15 a.m. the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 and they stated that currently there are four full-time social workers. They stated that for a short period of time they were down one social worker who was the Director of Social Services. Review of Resident R4's clinical record revealed the last social service note indicating a care plan meeting was held was dated March 6, 2025. Review of facility documentation dated October 17, 2025 states the resident has a BIMS (Brief Interview for Mental Status) score of 8 and there was no indication that the resident's representative listed on file was invited to the care plan meeting. During the tour of three nursing units on November 25, 2025 there were two residents that stated that they have not talked to the social worker since the old one no longer works at the facility. Observation was made of the third-floor nursing unit at 10:00 a.m. on November 25, 2025. During the observation Resident R5 was observed in bed with breathing treatment on. The resident had a clear medication bedside with about six to eight pills in it. Resident R5 asked for her social worker and stated, I have not seen or talked to one in months. Review of the clinical record for Resident R5 revealed the last care conference was held on May 29, 2025. Review of Resident R5's clinical record revealed the last social service progress note was from September 2, 2025. Prior to September 2, 2025 the last social service progress note was from July 30, 2025. Further review of random resident clinical record revealed Resident R7 had their last care conference held on July 25, 2025. At 12:34 p.m. Resident R6 approached the survey in the hall and asked if they were the social worker. When asked what he needed help with Resident R6 stated, I need to talk to the social worker, since mine left a few months ago I haven't heard anything. Review of Resident R6 record revealed the last care conference was held on May 29, 2025. Review of Resident R6's clinical record revealed the last social service progress note was from July 18, 2025. The current Director of Social Work Employee E4 was interviewed and has been employed only for a few weeks. Employee E4 did explain that there was no overlap with the old Director of Social Work. Employee E4 was asked about the care conference for R6, R5, and R7. Employee E4 stated that she knew there was an identified lapse with care conferences held. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.24(e)(4) admission Policy.

Based on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for two of three nursing units observed. (2nd floor and 3rd floor- Resident R1, Resident R2, Resident R3 and Resident 4)Findings Include:Review of facility policy titled, Safe and Homelike Environment ,dated November 25 states, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . Further review of the policy states, Definitions . Sanitary includes, but it not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but it not limited to, equipment used in the completion of the activities of daily living . Observations conducted of Resident R1's room on November 25, 2025 at 10:08am. revealed floor mats on both sides of the bed. The floormats were dirty will spills on them. The baseboard along the exterior wall was peeling off. There were small blue plastic caps and tube feed residue under and around the head of the bed. There was no liner in trash can that had trash in it. Observations conducted of Resident R3's room on November 25, 2025 at 10:10 a.m. revealed a floor mat that had peeled and stuck to the floor next to the bed. There was a trash can in the bathroom observed with no liner in trash can which contained soiled gloves. Observations of Resident R2's room on November 25, 2025 at 10:31 a.m. revealed that the center of the floor was dirty and sticky. Observation of the Resident R4's room on November 25, 2025 at 10:20 a.m. revealed when the door was opened feces were spread all over floor. When the surveyor began to exit the room a housekeeping staff, Employee E7 stated, I know he made a mess up in there but I am about to be going on break and he just went to the barber. Be back in about five minutes and I'm going to have that all cleaned up. Interview on November 25, 2025 at 10:27 a.m. with Licensed nurse, Employee E8 revealed that this can be a normal scene to walk into (feces smeared all over the floor) due to the resident having behaviors related to his colostomy bag. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, staff interviews, and observations it was determined that the facility failed to provide adequate supervision to possible prevent elopement and accidents for one of eleven residents (Resident R5).Findings Include: Review of facility policy titled, Medication Administration with a revision date of December 2024 states, Policy- Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Continued review of the facility policy states, .11. Administer medication as ordered in accordance with manufacturer specifications. Review of the facility policy titled, Elopement and Wandering Residents with a revision date of November 2024 states, Policy- This policy ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Further review of the policy states, Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door alarms to help avoid elopements. 2. Staff are to be vigilant in responding to alarms in a timely manner.3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Observation was made of the third floor nursing unit at 10:00 a.m. on November 25, 2025. During the observation Resident R5 was observed in bed with a breathing treatment on. The resident had a clear medication cup at bedside with about six to eight pills in it. The surveyor went and identified the licensed nurse Employee E8 who confirmed she had poured the medications but Resident R5 requested to have her breathing treatment first. Licensed nurse Employee E8 confirmed Resident R5 does not self-administer. Observation of the second floor nursing unit on November 25, 2025 at 10:33 a.m. revealed an elevator with a lock that needed a key to get up and down. After identifying the locked unit the surveyor went to the nurses station to ask for the key to access to elevator to exit. A nursing staff sitting behind the desk said it's probably in that black box over there and pointed towards the elevator. The surveyor began to walk towards the elevator to look for the key when a nurse aide, Employee E12 stated, Here I will show you, it's not supposed to be there, but oh look here it is. Employee E12 at 10:33 a.m. got me to the key from the grievance form box located to the right of the elevator on the wall. The wall was visible to all residents and visitors at the facility. Above the black box there was a white paper sign that stated, Please take the key back to the nurse's station. Interview held with the Nursing Home Administrator Employee E1, the Director of Nursing Employee E2, and the assistance director of nursing Employee E4 revealed that the key lock was implemented as a second step to ensure residents were unable to access the elevators. Employee E1 explained that the resident's wander guards (safety mechanism that locks doors and elevators) are what alerts staff that the residents is too close to the elevator or in jeopardy of eloping. Employee E4 stated that the key was implemented some time ago because staff were becoming desensitized to the wanderguards alarming from residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for two of 10 residents reviewed (R90 and R541) Findings include: Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. Review of Resident R90's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included difficulty in Walking, Weakness, Age related and Osteoporosis (condition that weakens bones, making them more likely to break), and Methicillin Resistant Staphylococcus Aureus Infection (MRSA- is a type of bacterial infection that has developed resistance to several common antibiotics, including methicillin and other beta-lactam drugs. MRSA can cause a range of infections, from mild skin issues to more serious bloodstream infections. It is spread through skin-to-skin contact or contact with contaminated surfaces). Review of physician order dated May 14, 2025, for R90, indicated an order stating, left buttock: cleanse with 0.125% Dakin's, lightly pack with 0.125% Dakin's moistened fluffed gauze, zinc oxide to peri wound cover with bordered foam, two times a day for wound care, and as needed for soiled/dislodged/incontinence care. Review of Resident R90's care plan indicated; Enhanced Barrier Precautions: Resident is at increased risk for infection related to wound and foley catheter, date initiated: May 29, 2025. On June 12, 2025, at 10:03 a.m., observed wound treatment administered by a Licensed Nurse, Employee E6; the nurse did follow physician order for left buttock wound treatment, except the Enhanced Barrier Precaution Procedure. After the wound treatment, Employee E6, could not discard the used gown in a protective bag, but carried the used gown exposed, outside the resident room. Employee E5, the Licensed Nurse who was assisting Employee E6, also could not discard the used gown in a protective bag, but carried the used gown exposed, outside the resident room and placed in an open trash box attached with the treatment cart. At the time of the finding, the above finding was confirmed with Employees E5, and E6. Review of Resident R541's Minimum Data Set (MDS- a federal mandated assessment tool for all residents) revealed admission assessment dated [DATE], revealed that the resident entered the facility on May 17, 2025, with diagnosis including hemiplegia (paralysis of one side of the body), respiratory failure and malnutrition. Resident R 541 with a brief interview of mental status revealed that this resident scored 9, indication of a moderately cognitively deficit. This resident required continuous oxygen therapy, indwelling urinary catheter, and a feeding tube. Observation of Resident 541 on June 10, 2025, at 12:02 p.m. revealed that this resident was receiving personal care by a nurse aide, Employee E20. This employee was observed not wearing the proper personal protection equipment (PPE) required for this task. Interview with Employee E20 at time of the above observation revealed that she was unaware that the gown was required unless actually performing wound care or urinary catheter care. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for three of 38 residents reviewed (Residents R90, R204, R541). Findings Include: Review of Resident R90's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included difficulty in walking, weakness, age related and osteoporosis (a condition that weakens bones, making them more likely to break). Review of physician order dated May 14, 2025, for Resident R90, indicated an order stating, left buttock: cleanse with 0.125% Dakin's, lightly pack with 0.125% Dakin's moistened fluffed gauze, zinc oxide to peri wound cover with bordered foam, two times a day for wound care, and as needed for soiled/dislodged/incontinence care. Observation conducted on June 11, 2025, at 10:03 a.m., of pressure ulcer treatment to Resident R90, revealed that the resident had a pressure wound at left buttocks. Review of the care plan for Resident R90, June 11, 2025, at 10:23 a.m., revealed that there were no focus, interventions, and outcomes (goals) care- planned for the care and treatment of the pressure wound at left buttocks of Resident R90. On June 11, 2025, at 10:27 a.m., interview with Employee E5, a Licensed Nurse, confirmed the above findings. Interview was held with Resident R204 on June 9, 2025 at 1:11 p.m. The resident discussed having wounds and being in pain. Observation of the resident's bed area revealed the resident had urinary catheter bag. Review of Resident R204's clinical record revealed the resident was admitted to the facility on [DATE]. Further review of Resident R204's record revealed the following diagnoses: Quadriplegia (dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord), Pressure-Induced Deep Tissue Damage of Left Hip, Pressure Ulcer of Right Upper Back, Pressure Ulcer of Left Buttock Unstageable, and Non-Pressure Chronic Ulcer of Other Part of Right Foot. Review of Residents R204's clinical record revealed the resident did not currently have an order for Enhanced Barrier Precautions. Further review of the resident's clinical order revealed the resident had an indwelling urinary catheter as of December 4, 2024. Further review of Resident R204's clinical record revealed the resident had a care plan dated March 4, 2025 revealed the resident did not have a baseline care plan in place for Enhanced Barrier Precautions related to the resident's pressure ulcers and urinary catheter care. Review of facility policy titled Safety and Supervision dated October 1st, 2021, revealed resident safety and supervision and assistance to prevent accidents are facility wide priorities. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accent hazards or risks for individual residents the team then shall target in our interventions to reduce individual risks implementing interventions to reduce accents or risk shall include communication specific interventions to all relevant staff, assigning responsibility, providing training, ensuring that interventions are implemented and documenting interventions. Review of Resident R541's Minimum Data Set (MDS- a federal mandated assessment tool for all residents) revealed admission assessment dated [DATE], revealed that the resident entered the facility on May 17, 2025, with diagnosis including hemiplegia (paralysis of one side of the body), respiratory failure and malnutrition. Resident R541 with a brief interview of mental status revealed that this resident scored 9, indicating moderately cognitively deficit. This resident required continuous oxygen therapy, a urinary indwelling catheter, and a feeding tube. Review of resident R541's nurses note dated June 5, 2025, revealed the resident in bed awake, alert, and oriented. and remained on 1:1 supervisor. Further review of clinical record nursing notes dated June 11, 2025, revealed resident continues on 1:1 for safety Review of resident's care plan revealed no plan of care for resident's need for one-to-one supervision for safety. Interview with Director of Nursing, Employee E3 on June 11, 2025, at 02:00 p.m. confirmed that the resident does not have a physician order for one-to-one supervision and there is no current care plan for the resident to be supervised. Employee E3 stated that the resident required supervision for safety. The resident had behaviors of pulling on tubing of feeding tube, oxygen, and catheter. This employee continued to describe the resident's safety precaution as evolving on the determination of the resident's mood daily, sometimes requiring one to one, sometimes monitored at nurses' station, or determining the resident's moods the resident can be left alone. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d) Nursing services

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise residents' care plan related to fall prevention, smoking supervision, and oxygen treatment for two of 38 residents reviewed. (Residents R111, and R150 ) Findings include: A review of the facility's policy titled comprehensive care plans dated October 1, 2024 revealed that the facility was responsible for the development and implementation of a comprehensive care plan for each resident. The care plan was developed and implemented to meet the medical, nursing and mental and psychosocial needs identified in the resident's comprehensive assessment. The policy indicated that an interdisiplinary care team was to participate in the development, implementation and revision of the care plan as needed to reflect measurable objectives and timeframes to meet the residents needs. Clinical record review for Resident R111 revealed a quarterly Minimun Data Set (MDS- assessment of resident's needs) dated May 2, 2025 that indicated this resident was cognitively intact and had a diagnosis of cerebralvascular accident with hemiparesis (weakness to one side of the body). The assessment indicated that this resident uses a wheelchair to ambulate and required the assistance of one staff member for transfers. On May 22, 2025 the nursing note indicated that Resident R111 was found on the floor next to the bed. Resident R111 had fallen from the bed. The resident sustained a laceration to her forehead from the fall. The physician had given orders to send the resident to the hospital post fall. The resident received dermabond (skin adhesive to hold wound edges together) to her forehead at the hospital. Observation of Resident R111 at 11:30 on June 9, 2025 revealed that the resident had a scoop mattress on her bed. Interview with Resident R111 at 11:30 a.m., on June 9, 2025 confirmed a fall in May, 2025. Clinical record review for Resident R111 revealed that the use of adaptive equipment (scoop mattress) to help prevent falls from bed. There care plan was not revised to reflect the use of a perimeter mattress to prevent falls. Interview with the licensed nurse, Employee E8 at 1:00 p.m., on June 9, 2025 confirmed that the use of a perimeter mattress as resident care equipment to prevent falls for Resident R111 had not been revised and documented on the care plan for Resident R111. Review of clinical records revealed that Resident R150 was admitted in the facility on May 6, 2025 with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD- long-term lung disease that makes it difficult to breathe), and adjustment disorder with mixed anxiety and depressed mood. Review of Resident R150's care plan revealed as follows under its focus area: The resident has, COPD. Date Initiated: May 7, 2025. Continued review of the reisdent's care plan revealed the following interventions area: Identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, etc. Further review of Resident R150's car plan revealed the following focus area: Resident wishes to smoke and is designated as safe Smoker; Date Initiated: May 14, 2025; . Resident will smoke safely in designated area and at scheduled times through next review; Date Initiated: 05/14/2025. Resident R150's care plan denoted a conflict between the resident's preference, and the outlined care interventions. 28 PA. Code 211.12(d)(1) Nursing services

Based on observations, resident interviews, staff interview, and review of facility policies, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment on one of four nursing units (Fourth floor). Findings Include: Review of facility policy titled, The Dining Experience undated states, Policy: The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Further review of the policy states, Procedure: 4. Tables will be properly set (forks on the left, knives and spoons on the right). Review of facility policy titled, Reheating Foods in Microwave with a revision date on October 1, 2024 states, Policy Interpretation and Implementation- 1. Meal trays will not be held on the nursing units for re-heating at a later time. Fresh trays will be prepared by the kitchen when the resident is available to eat or requests a particular item at a higher temperature or hot beverages between meals. Interview on June 9, 2025, at 1:15 p.m. with Resident R502 revealed about two weeks ago there was a leak in the bedroom from the unit above and water was pouring from the ceiling. Observations on June 9, 2025, at 1:17 p.m. of Resident R502's bathroom confirmed the ceiling tiles above the sink in the room and in bathroom had water damage and had a brown/yellow discoloration. Interview held with Resident R183 on June 11, 2025 at 10:10 a.m. and resident stated he gets back from dialysis sometimes not until 3:45 p.m. and his lunch tray is sitting at his bedside cold. Resident R183 stated, I do not eat or will eat the food cold because staff says they are not allowed to heat it up for me. Interview held with licensed nurse, Employee E16 on June 11, 2025 at 1:13 p.m. Employee E16 was seen assisting a nurse aide with passing out lunch trays to residents eating in their rooms. A lunch tray was observed sitting on a tray table bedside for Resident R183. Employee E16 was asked what they do for residents that have a dialysis chair time of 11:00 a.m. and are not back in time for lunch. Employee E16 stated, we set their lunch tray in the room and then when they get back we can reheat it for them if they want. When asked who heats up the lunch, Employee E16 stated, well we have a microwave on the unit, but that's usually just for employees so we send it back down to the kitchen. Observations on June 12, 2025, at 12:23 p.m. in room [ROOM NUMBER] revealed the panel on the wall was peeling off. Observation was made on June 12, 2025 at 12:43 p.m. of dining on the fourth floor. The residents were seated in the dining/activities room waiting for lunch starting around 12:40 p.m. Residents began being served their lunch at 1:18 p.m. by the nurse aides. All residents observed in the dining room were served their food on trays. All residents observed in the dining room were provided plastic silverware. There was no explanation of why the residents were given plastic silverware. 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on review of facility documentation, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure the resident environment remained free of accident hazards related to falls for three of six residents reviewed (Resident R65, R100, and R380). This failure resulted in actual harm for Resident R65 who sustained a fall out of bed and a laceration to the head requiring staples. Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of Resident R65's comprehensive care plan dated August 31, 2023, revealed the resident was at risk for falls related to poor safety awareness, weakness, and deconditioning. Review of Resident R65's March 2024 physician order summary revealed an order dated March 5, 2024, for bilateral floor mats to be on floor next to bed when resident is in bed. Review of Resident R65's clinical record revealed a nurse's note dated April 8, 2024, that Resident R65 was found on the ground next to bed with a laceration on top of the forehead. Review of facility documentation revealed an incident report dated April 8, 2024, completed by Registered Nurse Supervisor, Employee E8, which revealed Resident R65 sustained an unwitnessed fall on April 8, 2024, at approximately 3:15 a.m. Per the incident report, Resident R65 was found on the ground next to her bed. Resident R65 subsequently sustained a laceration to top of the forehead measuring 2 cm (centimeters) (length) x 1.5 cm (width) x 0.2 cm (depth) and was transferred to the hospital for evaluation. Further review of the incident report revealed the fall mat was not present on the floor at the time of the fall. Review of Resident R65's clinical record revealed Resident R65 was seen by psychiatry on April 8, 2024, where the resident reported she fell out of bed when she was reaching for her call bell. Review of Resident R65's clinical record revealed a skin and wound note dated April 9, 2024, by Nurse Practitioner, Employee E9, which revealed the resident's laceration was treated with four staples during her hospitalization on [DATE]. During an interview with Resident R65 on August 8, 2024, at 10:41 a.m. the resident confirmed hitting her head on the floor after falling out of bed on April 8, 2024. Resident R65 was in bed during the interview on August 8, 2024, at 10:41 a.m. and observations revealed fall mat was not on floor next to Resident R65's bed per physician orders. Interview on August 8, 2024, at 10:45 a.m. with Licensed Nurse, Employee E9, confirmed fall mat was not next to Resident R65's bed. Interview on August 8, 2024, at 11:00 a.m. with Licensed Nurse, Employee E11, confirmed Resident R65 hit her head on the floor after falling out of bed on April 8, 2024. The facility failed to ensure that a physican's order for bilateral floor mats were in place while Resident R65 was in bed. This failure resulted in actual harm to Resident R65 who fell from the bed, sustained a laceration to the head and required four sutures. Review of Resident R100's physician orders revealed an order dated June 10, 2024, for bilateral floor mats to be on the floor next to bed when resident is in bed. Review of Resident 100's admission MDS dated [DATE], revealed the resident was cognitively intact and had diagnoses of muscle weakness and lack of coordination. Review of Resident R100's comprehensive care plan dated July 25, 2024, revealed the resident was at risk for falls related to new and unfamiliar environment and sustained a fall on July 24, 2024. Observations on August 6, 2024, at 10:15 a.m. revealed Resident R100 was lying in bed and did not have bilateral floor mats on the floor next to the bed. Follow-up observations on August 6, 2024, at 12:12 p.m. revealed Resident R100 was still in bed and bilateral floor mats were still not in place. Interview on August 6, 2024, at 12:13 p.m. with Licensed Nurse, Employee E12, confirmed Resident R100 did not have bilateral floor mats while the resident was in bed. Observations with Licensed Nurse, Employee E12, revealed no floor mats were available in the resident's room. Clinical record review revealed Resident R380 was readmitted to the facility July 30, 2024 with a diagnosis that included but not limited to Asthma (a condition that affects your airways and makes breathing difficult), Repeated falls, Syncope and collapse (fainting), and Muscle weakness. Further review of clinical records revealed Resident R380 had a significant history of falls, which included two falls in the facility on January 15, 2024 and January 20, 2024. Review of Resident R380's physician orders revealed an order dated July 31, 2024, for bilateral floor mats to be placed on the floor next to bed when resident is in bed. Observations on August 6, 2024, at 10:47 a.m., revealed Resident R380 was lying in bed and did not have bilateral floor mats on the floor next to the bed. Follow-up observation on August 7, at 9:15 am, revealed Resident R380 was lying in bed and bilateral floor mats were still not in place. Interview on August 7, 2024, at 9:27 a.m., with Employee E13, Unit Clerk, confirmed Resident R380 did not have the required bilateral floor mats while the resident was in bed. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observation, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that the alarms on the stairwell and elevators doors were functioning properly resulting in one of ten residents (Resident R1) reviewed eloping from the facility, twice in 48 hours. This failure put the health and safety of residents at risk for continued elopement and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Elopement Risk Evaluation with Wanderguard (device designed to trigger an alarm if the person wearing the device moves outside a defined area), effective (MONTH) (YEAR), revealed that Elopement is defined as a resident who leaves the facility without the facility staff being aware that the resident has done so. The policy further indicated that all staff would be aware of any resident deemed to be at risk for elopement and that staff should review care plans and resident profiles for interventions related to wandering and elopement. Review of facility policy, Wanderguard/Elopement Procedure, dated last revised (MONTH) 2009, revealed that . Residents at risk for wandering are given a Wanderguard bracelet to wear . and . Routine checks for function are completed. Continued review of the policy indicated that . In the event a resident exits or attempts to exit any alarmed door or elevator, the alarm will sound at the front desk switchboard. The receptionist will call Code Blue. The nurse will immediately respond and check for the resident and if they are not present, they will initiate a search. Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of Resident R1's admission Minimum Data Set assessment (MDS -assessment of resident care needs) revealed that the resident was moderately cognitively impaired. Further review of the clinical record revealed a nurse's note dated (MONTH) 9, (YEAR), at 9:38 p.m. which indicated that the resident was identified as an elopement risk and placed on constant supervision. Continued review of Resident R1's clinical record revealed nurses' notes dated (MONTH) 12, (YEAR), at 8:17 a.m. which stated that the resident was exhibiting exit seeking behaviors and at 10:41 a.m. the resident left the unit through a locked door after a housekeeper and fell . Nurses' notes dated (MONTH) 14, (YEAR), at 4:03 p.m. revealed that Resident R1 was transferred to the 3rd floor (3C) Dementia Unit and at 5:37 p.m. a Wanderguard was placed on the resident's left ankle. Review of Resident R1's care plan dated initiated (MONTH) 9, (YEAR), revealed that the resident was identifed as at risk for elopement. A nursing intervention initiated (MONTH) 12, (YEAR), stated that the resident would be placed on 1:1 supervision when exhibiting exit seeking behaviors. Continued review of Resident R1's clinical record revealed a nurse's note dated (MONTH) 16, (YEAR), at 3:00 p.m. which revealed that Resident R1 was seen on the street approximately 1 1/2 blocks away from facility. The resident was brought back to the facility and placed on 1:1 supervision. A review of documentation submitted by the facility on (MONTH) 17, (YEAR), confirmed that on (MONTH) 16, (YEAR), at 10:22 a.m. Resident R1 exited the facility through a side door, that an employee saw the resident walking outside of the building and that the employee was able to encourage the resident to come back into the building. Continued review of facility documentation related to Resident R1's elopement on (MONTH) 16, (YEAR), revealed a witness statement provided by Security Guard 1 who stated that Resident R1 went out of the building for the second time in about the past 36 hours and that Resident R1 had exited out the same stairway on (MONTH) 14, (YEAR). Review of the Security Log book dated (MONTH) 14, (YEAR), revealed that Resident R1 went out of the building in stairwell C causing the alarm to go off. The resident was recognized and brought back into the building and a nurse took Resident R1 back to the Dementia Unit. Continued review of the Security Log book dated (MONTH) 16, (YEAR), revealed that Resident R1 went out again by way of stairwell C and that maintenance fixed the alarm that was broken on that door. Continued review of the clinical record for Resident R1 revealed a Mental Health/Behavior Services consultation dated and signed by a physician on (MONTH) 17, (YEAR). The consult indicated that nursing staff had reported to the physician that the resident eloped from the Dementia Unit on (MONTH) 14, (YEAR), and (MONTH) 16, (YEAR), and that on (MONTH) 16, (YEAR), the resident was found outside of the facility. Interview with the DON (Director of Nursing) on (MONTH) 26, (YEAR), at approximately 9:10 a.m. confirmed that Resident R1 had eloped from the Dementia Unit on (MONTH) 16, (YEAR), through the door to stairwell C. The DON further indicated that following Resident R1's elopement on (MONTH) 16, (YEAR), she arrived at the facility and found that the alarm on the exit door to stairwell C was not working. Continued interview with the DON on (MONTH) 26, (YEAR), revealed that the function of the alarms on all doors are checked daily and logged by the maintenance staff. Review of Maintenance Rounds documentation revealed that the function of the alarm on the door on the Dementia Unit to stairwell C was checked on (MONTH) 13, 14, 17, 21 and 25, (YEAR). Further review of the Maintenance Rounds documentation revealed no documentation that the function of the alarm of the door on the Dementia Unit to stairwell C was checked on (MONTH) 15 and 16, 18, 19, 20, 22, 23, and 24, (YEAR). Interview with the Maintenance Director on (MONTH) 26, (YEAR), at 11:58 a.m. confirmed that daily rounds of the Dementia Unit stairwell door alarms was not completed on eight of 26 days in December. Additionally, the interview with the Maintenance Director confirmed that the daily check of the function of the door alarms on the door on the Dementia Unit to stairwell C was not completed on (MONTH) 15 and 16, (YEAR), the day of Resident R1's elopement. A tour of the facility on (MONTH) 26, (YEAR), at 9:11 a.m. with the DON and the Assistant Director of Nursing (ADON) revealed that the Wanderguard alarm system on the service elevator did not alarm when tested . Interview with the ADON, at the time of the observation, confirmed that the Wanderguard alarm should have activated when the elevators doors opened on the Dementia Unit. Continued review of facility documentation related to the routine checks of the function of Wanderguard alarms on the Dementia Unit main and service elevators revealed no documentation that they had been checked in the month of December. Additional interview with the Maintenance Director on (MONTH) 26, (YEAR), at 11:58 a.m. confirmed that there was no facility documentation that the function of the Wanderguard alarms on the Dementia Unit service elevator or main elevators had been checked on a regular basis. The Maintenance Director further indicated that he was unaware of the exact date that the service elevator Wanderguard alarms on the Dementia Unit had been checked. Further interview with the DON on (MONTH) 26, (YEAR), at approximately 9:10 a.m. revealed that there were six residents in the building, identifed as at increased risk for elopement from the facility. The DON further indicated that all six residents had Wanderguard bracelets placed and resided on the Dementia Unit. Further interview with the Maintenance Director revealed that he could not explain why the Wanderguard alarm did not trigger during the tour with the DON and ADON on (MONTH) 26, (YEAR), at 11:17 a.m. Interview with Security Guard 2 on (MONTH) 26, (YEAR), at 2:43 p.m. confirmed that on (MONTH) 14, (YEAR), between 7:00 p.m. and 9:00 p.m. Resident R1 had exited the door of stairwell C at the ground level which leads to the facility parking lot. Interview with Employee E7 on (MONTH) 26, (YEAR), at 3:28 p.m. revealed that on (MONTH) 14, (YEAR), at approximately 7:00 p.m. he saw Resident R1 sitting down in the lobby. Employee E7 confirmed that he was Resident R1's nurse, that Resident R1 was last seen at the nurse's station between approximately 6:15 p.m. to 7:00 p.m. and that no alarms were heard on the unit to indicate that Resident R1 had opened the door to stairwell C and/or left the unit. Additonally, Employee E7 indicated during the interview that he did not report the incident to the nursing supervisor. Based on the above findings Immediate Jeopardy to the health and safety of the residents was identified to the NHA and DON on (MONTH) 27, (YEAR), at 2:23 p.m. and an immediate action plan was requested. On (MONTH) 27, (YEAR), at 5:50 p.m. the facility's immediate action plan was accepted and included: 1. Facility did immediate QAPI (Quality Assurance Performance Improvement) meeting related to elopements and root cause analysis, functioning of Wanderguard system on service elevator and communication between staff in the event a resident attempt to exit any alarmed door or elevator. 2. Facility took immediate action by contacting vendor (service elevator) for proper functioning. Immediately staff placed at area for resident safety until vendor arrives and issue was resolved. Facility educated the front desk employee immediately on communicating with Administrator and DON in the event a resident attempts to exit any alarmed door or elevator. 3. Facility immediately reviewed and revised policy on Wanderguard/elopement procedure to reflect daily Wanderguard checks which will be checked for placement on all shifts and checked for function daily on 11-7 shift by nursing staff. Wanderguard alarm system which includes service elevator will be checked and logged daily by maintenance on 7-3 shift. Log will be based on specific elevator checks (I.e. service elevator), date and times checked, and any issues identified will be immediately reported to the Administrator/DON or designee for problem solving. 4. Facility immediately started education of all employees on elopement and Wanderguard procedure. Education will be provided to all staff prior to start of their shift including front desk reception staff, housekeeping, maintenance, security, activities, dietary, therapy, social services, and administration throughout the shift until 75% compliance is achieved on education by Wednesday (MONTH) 2, 2019. Education will continue until 100% compliance is achieved. 5. Facility will review clinical documentation regarding Wanderguard function checks and Wanderguard system log daily to assure compliance and all findings will be reported to QAPI committee. Following verification of the implementation of the immediate action plan and review of staff re-education documentation, the Immediate Jeopardy was lifted on (MONTH) 28, (YEAR), at 4:15 p.m. The facility failed to ensure that the alarm on the door to stairwell C and the Wanderguard alarm on the service service elevator on the Dementia Unit were monitored and maintained in working order which resulted in one resident eloping from the facility twice within a 48-hour period, placing this and other residents at risk for continued elopements and creating an Immediate Jeopardy situation. Free of Accident Hazards/Supervision/Devices CFR(s) 483.25(d)(1)(2) - Previously cited 11/27/18, 03/03/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/27/18, 11/17/17, 03/24/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16 28 Pa. Code 201.18(a) Management Previously cited 11/27/18, 11/17/17 28 Pa. Code 201.18(b)(1) Management Previously cited 11/27/18, 11/17/17, 03/24/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16 28 Pa. Code 201.18(b)(3) Management Previously cited 11/27/18, 11/17/17, 03/24/17, 01/25/17, 11/03/16, 10/21/16, 03/03/16 28 Pa. Code 201.18(e)(1) Management Previously cited 11/27/18, 11/17/17, 08/02/16, 03/03/16 28 Pa. Code 211.5(f) Clinical records Previously cited 11/27/18, 11/17/17, 03/03/16 28 Pa. Code 211.5(h) Clinical records Previously cited 11/27/18 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/27/18, 11/17/17, 03/03/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/27/18, 11/17/17, 03/24/17, 01/25/17, 11/03/16 28 Pa. Code 211.12(c) Nursing services Previously cited 11/27/18, 11/17/17, 01/25/17, 11/03/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/27/18, 11/17/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 11/27/18, 11/17/17, 03/24/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16

Based on observations, interviews with the resident and staff, review of clinical records and facility policy, it was determined that the facility failed to respond to a resident in severe pain, seek an alternative pharmacological approach when medication failed to relieve pain, apply interventions to reduce pain during anticipated treatment of [REDACTED]. (Resident R415) Findings include: Review of the facility's policy titled, Pain Management, dated (MONTH) 2009, revealed the policy is to assess residents' comfort level and through a team approach, utilize pain management techniques. Residents with a medical condition causing pain will be managed through an interdisciplinary approach. Residents identifying as having pain will be asked the degree of pain according to the pain scale. The cognitively impaired residents will be assessed by observation indicators such as verbalization, vocalization, facial expression, body action, and behavior. Doses will be scheduled on a regular schedule to maintain the level of drug that will help prevent recurrence of pain. Ask the resident at what number on the pain scale of 0-10 would the pain be at its worse, 7 thru 10 would equal severe to worst pain, 4 thru 6 would be moderate and 1 thru 3 would be mild pain. Review of Resident R415 clinical records revealed an admitted (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. bone marrow, usually due to infection), which was a deep, large wound on the sacral area that affected the bone, muscles and ligaments, causing a bone infection that went into the bloodstream (sepsis). Also included in the [DIAGNOSES REDACTED]. Resident R415 also had [DIAGNOSES REDACTED]. Review of the admission note dated (MONTH) 28, (YEAR), revealed Resident R415 was awake, alert, oriented, and able to make her needs known. Review of Resident R415's care plan for chronic pain included interventions to administer [MEDICATION NAME], anticipate the resident's needs for pain relief, and to respond immediately to any complaint of pain but failed to include interventions using a non-pharmalogical approach when pain existed. Review of Resident R415's care plan for chronic pain revealed interventions to anticipate the resident's needs for pain relief, and to respond immedicately to any complaint of pain. Further review of the care plan revealed no interventions using a nonpharmalogical approach Crevealed Review of the Occupational Therapy evaluation notes dated (MONTH) 10, (YEAR), revealed that Resident R415 needed increased assistance from others related to limited and painful movements. The evaluation further stated the resident had impaired range of motion on her bilateral upper extremities which included both her shoulders, elbows, forearms, wrists and hands and was totally dependent on staff for eating, toileting, dressing, bed mobility, and hygiene. Review of the Physical Therapy evaluation notes dated (MONTH) 10, (YEAR), revealed that Resident R415 presented with severe pain on the sacral area, the patient verbalized constant pain at rest and with movement on a scale of 10/10. It further states the progress and response to treatment was yet to be attained, limited due to pain associated with sacral wound and confusion. Review of the Speech Therapy evaluation dated (MONTH) 14, (YEAR), stated the patient expressed pain and discomfort throughout session. Resident R415 was first heard crying out in pain by the surveyor on (MONTH) 20, (YEAR), at 11:30 a.m. The resident was lying in bed and appeared disheveled. Her lips were dry and peeling, both eyes were discolored and swollen from the [DIAGNOSES REDACTED]. Tearfully, several times, she cried out saying her legs hurt and she couldn't move them. The resident revealed that she hollered out for help to a couple people that passed her room and they never stopped. The resident explained, They just kept on walking. I told the man who came in my room (Housekeeper, Employee E9) I told him I was in pain and I needed water, he never helped me, he kept mopping the floor, then he shut my door when he left. Review of Resident R415's physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the wound consultant record's dated (MONTH) 16, (YEAR), described Resident R415's sacral wound as 15.1 centimeters (cm) long, 19.0 cm in width and 1.9 cm in depth, equivalent to 6 x 7 x 1 inches. The physician's note dated (MONTH) 26, (YEAR), indicated the resident also had ulceration to her right shin, right hip and second toe. On (MONTH) 21, (YEAR), at 9:30 a.m. the resident was observed sighing and grimacing as she expressed she was in a lot of pain, I'm not positioned right, my butt hurts, my legs hurt, my whole body hurts, I feel like I'm sitting on a sack of something. The same day at 11:00 a.m. the resident's wound treatment was observed being done by Licensed Practical Nurse (LPN), Employee E10. The LPN stated the resident was pre-medicated for pain, (records showed 2 [MEDICATION NAME] tablets were given at 9:49 a.m. for pain of 10/10). At the start of wound care, the LPN repositioned Resident R415's legs to place her on her side. Immediately the resident cried out in pain when her legs were moved. The resident's pain was observed to increase when the soiled bandages were being removed from the sacral wound. The LPN had difficulties removing the soiled dressings and took several minutes to remove them. The resident cried out in pain with tears in her eyes, asking the nurse when it would be over. During that time, the LPN did not assess the level of pain the resident was experiencing nor offer if she wanted to stop the treatment. When the surveyor asked the resident to describe her pain, she verbalized her pain was 8 out of 10, indicating she was in severe pain. The resident continued to clenching her teeth while her body tensed-up in pain. The surveyor reiterated the level of pain the resident stated she was in but the nurse continued with the treatment without acknowledging her pain. During an interview with the Medical Director on (MONTH) 21, (YEAR), at 3:00 p.m. it was revealed that he was not aware of Resident R415 increased pain. The Medical Director indicated the nursing notes showed the opposite. The surveyor brought to his attention that LPN, Employee E7 knew of the resident pain by stating, She's always in pain. He was informed during wound care that the staff failed to anticipate the severity of her pain by pre-medicating her with medication used for mild pain. The Medical Director was made aware that LPN, Employee E10, failed to assess the resident's pain during wound treatment nor asked the resident if she was able to continue when she verbally stated she was in severe pain. The facility failed to respond to the resident's pain, failed to appropriately medicate prior to an anticipated treatment that caused severe pain, failed to use non-pharmacological approaches, failed to seek alternative medications when the current medication failed to relieve pain, and failed to recognize verbal and nonverbal indicators of pain for one resident. Pain Management CFR(s): 483.25(k) - Previously cited 11/17/17 28 Pa. Code 211.5(f) Clinical records Previously cited 11/17/17, 03/0316 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/17/17, 03/03/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/17/17, 03/24/17, 01/25/17, 11/03/16 28 Pa. Code 211.12(c) Nursing services Previously cited 11/17/17, 01/25/17, 11/03/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/17/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 11/17/17, 03/24/17, 01/25/17, 11/03/16, 10/21/16, 08/02/16, 03/03/16

Based on review of a clinical record and facility documentation and interviews with facility staff, it was determined that the facility failed to properly assess one resident (Resident CL1) who experienced a change in condition resulting in actual harm in one of one closed clinical record reviewed. Findings include: Review of Caring Heart Policies and Procedures, Cardiopulmonary Resuscitation (CPR), dated February 2015 and revised [DATE], revealed . Documentation .1. Document the following in the resident's medical record (if the victim is a resident): (a) The condition in which the resident was found or the witnessed event (b) The victim's response to resuscitation efforts (c) The approximate time that the EMS team took over (d) Time of death or time the resident was transported Review of resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], from a hospital with [DIAGNOSES REDACTED]. palsy (a group of neurological disorders that appear in infancy and permanently affect body movement, muscle coordination and balance), [MEDICAL CONDITION](a faster than normal heart rate at rest) and dysphagia (difficulty swallowing). Review of the resident's Medication Administration Record [REDACTED]. It is indicated for patients who have a functioning gastro-intestinal tract but are unable to take oral feedings) via a PEG tube (Percutaneous Endoscopic Gastrostomy tube placement which is indicated if enteral feeding is planned for more that one month). Review of resident's Medication Administration Record [REDACTED]. Review of the resident's plan of care created on [DATE], revealed that resident CL1 required a tube feeding related to a swallowing problem and the goal was that the resident will remain free of side effects or complications related to the tube feeding through the review date of [DATE]. Another goal was that Resident CL1 would be free of aspiration (when food or fluids enters the lungs rather than the stomach) through the review date of [DATE], and the interventions included: listen to lung sounds, monitor/document/report to MD as needed for the following, aspiration-fever, shortness of breath, feeding tube dislodged, infection at feeding tube site, tube dysfunction or malfunction, abnormal breath sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation, diarrhea, nausea/vomiting, dehydration. Review of the physician's progress note dated [DATE], revealed that Resident CL1 had a history of [REDACTED]. Food or liquid can also be aspirated from your stomach when it backs up into your esophagus). The note indicated to continue aspiration precautions (interventions which reduce the possibility of aspiration), including elevate head of bed 45 degrees during feeding and one hour after; check residual (the amount of fube feeding fluid remaining in the stomach) every eight hours-if 200 ml or greater, hold feeding for one hour and recheck. If residual remains 200 ml or over, notify physician and document amount; every shift , flush tube with 50 ml of water before and after each medication pass and 5 ml of water between each medication; flush tube with 250 ml of water every eight hours, for a total volume of flushes equal to 750 ml/24 hours excluding medication flushes. Review of the progress notes on Resident CL1's clinical record revealed that on [DATE], at 3:49 a.m. The Licensed Nurse, Employee E1, changed the resident's wound dressing. The next progress note was dated on [DATE], at 4:00 a.m. and the nurse was responding to a STAT (an abbreviation of the Latin statim, meaning immediately. STAT can be a code called for an emergency response to alert staff ) page and upon arrival to the floor CPR (cardio-pulmonary resuscitation, an emergency procedure that combines chest compressions with artificial ventilation to preserve intact brain function in a person whose heart or breathing has stopped) was in progress, the EMS (Emergency Medical Services, also known as ambulance or paramedic services, dedicated to providing out of hospital medical care and medical transportation for patients) system was activated and [DATE] was in route. A nurses' note completed by the Registered Nurse Supervisor, Employee E2, on [DATE], at 4:08 a.m. revealed that CPR was in progress, no shock was advised per the AED (Automatic External Defribulator). The note also indicated that the EMS unit had arrived and had assumed care. A nurses' note completed by the nursing suipervisor at on [DATE], at 4:21 a.m. revealed physical death was pronounced at this date and time. A nurses' note completed on [DATE], at 5:03 a.m. revealed that at 3:50 a.m. Employee E3 a NA (Nursing Assistant), reported that the resident did not look. When the nurse entered the room the resident was observed in bed with the head of the bed elevated at least 45 degrees. The resident was pasty and lightly cyanotic (blue in color). There were no signs of viable life, no pulse. A STAT was called and initiated. The team responded and the resident was pronounced dead at 4:21 a.m. An interview on [DATE], at 11:10 a.m. with Employee E4, the Unit Manager for the Third Floor Cliveden Unit, confirmed that there was limited documentation prior to the death of the resident. Employee E4 stated that she had looked for a Code Response Sheet but was unable to locate one. The facility failed to complete a Code Response Sheet as required by the facility's policy. An interview on [DATE], at 1:00 p.m. with Employee E1, the nurse assigned to CL1 on the night of [DATE], revealed a dressing change was completed at 3:49 a.m. as ordered. While Employee E1 was documenting the dressing change, the NA who had been assisting called Employee E1 back into the resident's room to look at the resident. The resident had vomited a scant amount of tube feeding fluid. The NA was instructed to clean up the resident. A second NA arrived to assist and asked Employee E1 to check the resident and found the resident's color was pasty and there was no pulse. Employee E1 checked the computer to determine if the resident was a DNR (Do Not Resuscitate - indicating that CPR was not to be performed in the event of a [MEDICAL CONDITION]). Employee E1 ran back to the resident's room, called a STAT, and Employee E5 arrived with the crash cart and CPR was started. An interview on [DATE], at 10:45 a.m. with Employee E5, a NA revealed that they had been asked to assist with a dressing change for Resident CL1. Following the dressing change Employee 5 walked by Resident CL1's room and heard gurgling, stating that it sounded like the resident was choking. Employee E1 was advised of the choking sound and informed Employee E5 that the resident always does that, it is normal for her, and Employee E5 was instructed to clean the resident up. Aproximately 10 to 20 minutes later Employee E1 checked on the resident. When Employee E1 checked on the resident a STAT was called and Employee E5 went to get the crash cart. During the interview Employee E5 stated that the dressing change was completed aproximately 1 hour prior to the STAT being called. An interview on [DATE], at 11:20 a.m. with Employee E3 revealed that the resident was coughing through the shift and that Employee E1 was informed and advised Employee E3 that this was normal for the resident. Employee E3 was called away to another floor to assist with another resident and when Employee E3 returned and checked on Resident CL1 the resident was observed coughing up tube feeding fluid. The resident was gray and purple-ish. Employee E1 arrived in the resident's room and a STAT was called. When Employee E5 and Employee E1 were doing post mortem care the resident was rolled over to clean her back and the tube feed was coming out of the resident's mouth and nose and it was all over her hair. The resident's orders and care plan identified the resident as being at risk for aspiration. The facility failed to implement interventions to assess the resident for aspiration in a timely manner resulting in the resident's death. 42 CFR 483.25 Provide Care/Services for Highest Well Being Previously cited [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records, facility documentation and facility policies, and interviews with staff, it was determined that the facility failed to adequately address the increased nutritional requirements related to significant weight loss that resulted in actual harm for one of 31 reviewed (Resident R196). Findings include: Review of facility policy, Weight Assessment and Intervention, dated revised February 2011, indicated that it is the policy of the facility to, . prevent, monitor, and intervene for undesirable weight loss . The policy defined significant weight loss with the following criteria: a five percent weight loss over one month, a seven and a half percent weight loss over three months, and a ten percent weight loss over six months. The policy also stated that any weight loss that exceeded these established parameters would be considered severe. A review of the clinical record for Resident R196 revealed that the resident had been readmitted to the facility on [DATE], with diagnoses, including but not limited to, [MEDICAL CONDITIONS] (damage to the brain from a lack of oxygen). At the time of admission, the resident was comatose (state of profound unconsciousness), with a [MEDICAL CONDITION] (tube inserted through the neck to assist in breathing). The resident's diet was NPO (nothing by mouth). The resident had a gastrostomy (feeding tube) through which the resident received enteral (liquid feedings) nutrition, medications and water. The resident's prognosis (a prediction of the resident's probable outcome) at the time of admission was poor and the resident was subsequently place on hospice (end of life care) services. In addition, the resident's code status was changed to DNR (DNR-do not resuscitate-no heroic efforts in the event of an emergency). Review of Employee E5, registered dietitian, progress note dated [DATE], at 10:39 a.m., indicated that Resident R196 had weighed 304.3 pounds on admission. The resident had been had been placed on a tube feeding of Glucerna 1.2 at 50 cc/hr to run over a 22 hour period with water flushes of 200 cc every six hours. This formula provided the resident with 1320 calories (approximate energy value of food ) 1900 cc of fluids and 66 grams (a unit of mass) of protein. The dietician indicated that the resident's estimate nutrient needs based on the residents' height, weight and current medical condition was ,[DATE] calories, ,[DATE] cc fluid and ,[DATE] grams of protein. The dietitian further noted that Resident R196 had been tolerating the prescribed tube feedings without any signs or symptoms of aspiration (inhaling as foreign material such as a tube feeding). The dietitian indicated that Resident R196 was a high nutrition risk due to the necessity of the tube feeding. The dietitian recommended that the current tube feeding rate be increased to 60 cc/hr to infuse over 22 hours. The increased rate would provide Resident R196 with 1785 calories, 1320 cc fluid and 79 grams or protein. In addition, the dietician recommended the addition of 30 cc of Prostat (a protein supplement) which would provide an additional 100 calories and 15 grams of protein. On [DATE], at 2:43 p.m., the resident was noted with decreased urine output (indication of dehydration). The dietitian recommended that Resident R196's water flushes be increased to 250 cc every six hours. this would provided the resident with 1000 cc of water in 24 hours. On [DATE], the dietitian further recommended that Resident R196's protein supplement, Prostat, be increased to twice daily. On [DATE], Resident R196 was noted with a new pressure ulcer to the right lateral foot. The ulcer was noted as 3.0 centimeters (cm) long by 1.0 cm wide by 0.1 cm deep. A Skin/Wound note dated [DATE], at 1:19 p.m., indicated that in addition to the pressure ulcer to the right lateral foot, facility staff had identified a new skin tear to the resident's right buttock. No changes were made to the residents' tube feeding regime or protein supplementation as a result of the new skin alterations. On [DATE], Resident R196's weight was noted as 268.4 pounds. This represented a loss of 34.8 pounds over three weeks. This reflected an 11.2 percent loss over thirty days which per facility policy indicated both a significant and a severe weight loss. Employee E5, registered dietitian, notified the resident's physician of the resident's significant weight loss. There were no changes made to the resident's tube feeding regime or protein supplements as a result of the presence of the new wound or the 34.8 pound weight loss. On [DATE], at 12:46 p.m., Resident R196 was noted with new changes to an existing alteration on the skin of the resident's sacrum (lower back). A physician's progress note dated [DATE], at 6:12 p.m., indicated that the resident's sacral ulcer was worsening. No new changes were made to the residents' tube feeding regime or protein supplementation. On [DATE], the physician ordered Resident R196's tube feeding of Glucerna 1.2 be decreased to 40 cc per hour and decreased the length of the feeding from 22 to 20 hours. Employee E5's dietary note dated [DATE], indicated that the resident had sustained a significant weight loss of greater than ten percent over six months which, per facility criteria, also represented a severe weight loss. Further review of the dietary note dated [DATE], indicated that the physician was aware of the resident's severe weight loss. Employee E5 recommended that the resident's protein supplement, Prostat, be increased to three times daily to help meet the resident's estimated nutrient needs. physician progress notes [REDACTED]. No changes were made to the resident's tube feeding. Review of the dietitian notes dated [DATE], at 11:42 a.m., revealed that Resident R196 was noted with a continued significant and severe weight loss of greater than ten percent over 180 days. The physician again was noted as aware of the weight loss. Employee E5 further indicated that the resident had been maintained on a low rate, low volume , low calorie tube feeding as per the physician's orders [REDACTED]. Further review of the clinical record for Resident R196 revealed that the resident had been discontinued from hospice services on [DATE]. The resident's code status was subsequently changed back to a full code which indicated that the resident was to be resuscitated and that the facility would perform CPR in the event of an emergency. There was no clinical documentation that Resident R196's nutritional status had been reassessed at the time the resident was removed from hospice services, a significant change related to the resident's plan of care. On [DATE], the resident's weight was 269.0 pounds. On [DATE], Resident R196's weight was noted as 202.6 pounds. This reflected a loss of 66.6 pounds from [DATE]. The resident was subsequently reweighed on [DATE], and noted to weigh 202.1 pounds. Dietitian notes dated [DATE], confirmed that the resident had sustained 66.6 pound weight loss over thirty days. This weight reflected a 24.7 percent loss over thirty days which again equated with both a significant and a severe weight loss for this resident. The physician was noted as aware of the weight loss. Clinical documentation further indicated that the physician wanted the resident maintained on a hypocaloric feeding regime secondary to the resident's obesity and the high risk of aspiration. On [DATE], the resident was subsequently transferred to the hospital with respiratory distress. The resident was admitted to the hospital with [REDACTED]. Further review of the resident's weight record indicated the resident's most recent weight was on [DATE]. At that time, Resident R196 was noted as 185.8 pounds, which reflected a continued weight loss. Review of Progress notes indicated that the resident's physician prescribed a hypocaloric, low volume, low rate tube feeding with the intention of reducing the resident's weight and risk of aspiration. Review of the clinical record dated [DATE], through [DATE], approximately eight months, revealed no documentation that the resident had not tolerated the tube feedings at the prescribed rates. In addition, there was no documentation that the facility had reassessed the resident for a possible trial of a gradual increase in the tube feeding rate to provide the resident with additional calories in the presence of ongoing significant and severe weight loss and the presence of multiple wounds. Additionally, the dietitian's clinical documentation dated [DATE], indicated that for Resident R196, a modest weight loss was desirable. Further review of the dietitian's notes indicated that the goal for this resident was a gradual weight loss which the dietitian defined as a loss of one to two pounds per month. Per resident R196's weight records this resident has sustained an actual loss of 118. 5 pounds in eight months. The facility failed to ensure that this resident who, had been identified as high nutritional risk, was provided with appropriate nutritional support in the presence of ongoing weight loss and multiple alterations in skin integrity. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited [DATE]. 28 PA Code: 201.18(b)(1) Management. Previously cited [DATE]. 28 PA Code: 211.6(d) Dietary services. 28 PA Code: 211.12(d)(1)(2)(3)(5) Nursing services. Previously cited [DATE].